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Balbo S, Pini CM, Raffaldi I, Delmonaco AG, Castagno E, Guanà R, Di Rosa G, Bondone C. Accuracy of point-of-care ultrasound in the diagnosis of acute appendicitis in a pediatric emergency department. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:485-490. [PMID: 38436504 DOI: 10.1002/jcu.23658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE To investigate the accuracy of point-of-care ultrasound (PoCUS) in diagnosing acute appendicitis in children; to evaluate the concordance between PoCUS performed by a pediatric emergency physician (PedEm) and ultrasonography (US) performed by a radiologist; to draw a "learning curve." METHODS We prospectively enrolled children aged 0-14 years old led to the Emergency Department of Regina Margherita Children's Hospital, from January 2021 to June 2021, with suspected acute appendicitis. PoCUS was performed by a single trained PedEm, blindly to the radiologist's scan. A "self-assessment score" and the "time of duration of PoCUS" were recorded for each patient. Final diagnosis of appendicitis was made by a pediatric surgeon. RESULTS We enrolled 62 children (2-14 years). Overall sensitivity of PoCUS was 88%, specificity 90%; PPV 90.6%, and NPV 86.6%. Global concordance between the PedEm and the radiologist was good/excellent (k 0.74). The mean duration of PoCUS significantly decreased during the study period, while the self-assessment score increased. CONCLUSION This is a preliminary study that shows the effectiveness of PoCUS in diagnosing acute appendicitis; furthermore, it shows how the PedEm's performance may improve over time. The learning curve showed how the experience of the PedEm affects the accuracy of PoCUS.
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Affiliation(s)
- Stefano Balbo
- Emergency Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Cecilia Maria Pini
- Emergency Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Irene Raffaldi
- Emergency Department, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Emanuele Castagno
- Emergency Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Riccardo Guanà
- Pediatric Surgery Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Gianpaolo Di Rosa
- Radiology Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Claudia Bondone
- Emergency Department, Regina Margherita Children's Hospital, Turin, Italy
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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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Adhikari S, Leo M, Liu R, Johnston M, Keehbauch J, Barton M, Kendall J. The 2023 Core Content of advanced emergency medicine ultrasonography. J Am Coll Emerg Physicians Open 2023; 4:e13015. [PMID: 37564703 PMCID: PMC10411060 DOI: 10.1002/emp2.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Megan Leo
- Department of Emergency MedicineBoston Medical CenterBostonMassachussetsUSA
| | - Rachel Liu
- Department of Emergency MedicineYale UniversityNew HavenConnecticutUSA
| | - Mary Johnston
- American Board of Emergency MedicineEast LansingMichiganUSA
| | | | - Melissa Barton
- American Board of Emergency MedicineEast LansingMichiganUSA
| | - John Kendall
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
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4
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Boyle MJ, Lin-Martore M, Graglia S. Point-of-care ultrasound in the assessment of appendicitis. Emerg Med J 2023; 40:528-531. [PMID: 37277167 DOI: 10.1136/emermed-2022-212433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Michael Jarvis Boyle
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Margaret Lin-Martore
- Departments of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sally Graglia
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Altuğ E, Şener K, Çakir A, Erdem ZB, Eyüpoğlu G, Güven R. Accuracy of emergency physician bedside ultrasonography compared with private teleradiologist for acute appendicitis diagnosis. Ir J Med Sci 2023; 192:1473-1479. [PMID: 36076151 DOI: 10.1007/s11845-022-03149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Acute appendicitis (AA) is a common cause of abdominal pain resulting in admission to the emergency room. Imaging methods such as ultrasonography and CT are usually used for diagnosing acute appendicitis. Reports regarding CT scans conducted during night shifts are prepared by private teleradiologists. AIMS The aim of this study was to compare the accuracy of point-of-care ultrasound performed by an emergency medicine specialist and private teleradiologists in the diagnosis of AA. METHODS This study was conducted prospectively and in a single center in the emergency department of a tertiary hospital. Patients who were admitted to the study between 15.09.2020 and 15.09.2021 and were diagnosed with AA who met the study criteria were included. A total of 134 patients diagnosed with AA, who met the inclusion criteria, out of 158 operated patients were included in the study. RESULTS In the study, 77 were male and 57 were female. The mean age of patients with histopathologically positive AA was 31 and 31.5 in negative patients. The sensitivity and specificity of POCUS performed by the emergency physician and private teleradiology for the diagnosis of AA were 78.4% and 59.3% and 58.8% and 53.1%, respectively. CONCLUSIONS POCUS performed by an emergency medicine specialist showed a higher sensitivity for the diagnosis of AA compared with private teleradiology. Hence, POCUS is more successful in diagnosing AA than private teleradiology. In conclusion, we recommend the concurrent use of AS and POCUS in emergency departments rather than private teleradiology for the diagnosis of AA.
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Affiliation(s)
- Ertuğrul Altuğ
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey.
| | - Kemal Şener
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Adem Çakir
- Department of Emergency Medicine, Ministry of Health of Turkey Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Zeynep Betül Erdem
- Department of Medical Pathology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Gökhan Eyüpoğlu
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Ramazan Güven
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
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Diercks DB, Adkins EJ, Harrison N, Sokolove PE, Kwok H, Wolf SJ, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med 2023; 81:e115-e152. [PMID: 37210169 DOI: 10.1016/j.annemergmed.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Cho SU, Oh SK. Accuracy of ultrasound for the diagnosis of acute appendicitis in the emergency department: A systematic review. Medicine (Baltimore) 2023; 102:e33397. [PMID: 37000097 PMCID: PMC10063291 DOI: 10.1097/md.0000000000033397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Point-of-Care Ultrasound (POCUS) is a quick, useful, noninvasive, and inexpensive diagnostic tool used for the diagnosis of trauma, abdominal pain, dyspnea, and chest pain in the emergency department (ED). However, the diagnostic accuracy of ultrasound in the ED may be different from those reported in previous studies owing to the setting and time constraints in ED. METHODS We conducted our study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A literature search was conducted using databases on US National Library of Medicine's database of biomedical literature, Ovid MEDLINE, online database of biomedical articles, and the collection of databases of systematic reviews and other evidence. The inclusion criteria were the use of bedside ultrasound as a diagnostic tool for acute appendicitis in the ED and the available data on diagnostic parameters such as sensitivity, specificity, and positive and negative predictive values (NPV). We constructed forest plots and summary receiver operating characteristic curves to evaluate the diagnostic accuracy of bedside ultrasound for acute appendicitis in the ED. RESULTS A total of 21 studies that met the inclusion criteria of this study were included for analysis. The overall pooled sensitivity was 0.81 (95% CI, 0.78-0.83), whereas the pooled specificity was 0.87 (95% CI, 0.85-0.88). However, the I2 test showed 91.7% and 90.9% heterogeneity in the sensitivity and specificity values, respectively. The summary receiver operating characteristic curves showed high levels of accuracy, as evidenced by an area under the curve of 0.9249 (standard error: 0.0180). CONCLUSIONS The use of ultrasound for the diagnosis of acute appendicitis in the ED showed that ultrasound has high overall sensitivity and specificity for the diagnosis of acute appendicitis. however, high heterogeneity among the included studies was observed.
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Affiliation(s)
- Sung Uk Cho
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Se Kwang Oh
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
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8
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van Wassenaer EA, Daams JG, Benninga MA, Rosendahl K, Koot BGP, Stafrace S, Arthurs OJ, van Rijn RR. Non-radiologist-performed abdominal point-of-care ultrasonography in paediatrics - a scoping review. Pediatr Radiol 2021; 51:1386-1399. [PMID: 33837798 PMCID: PMC8266706 DOI: 10.1007/s00247-021-04997-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/06/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Historically, US in the paediatric setting has mostly been the domain of radiologists. However, in the last decade, there has been an uptake of non-radiologist point-of-care US. OBJECTIVE To gain an overview of abdominal non-radiologist point-of-care US in paediatrics. MATERIALS AND METHODS We conducted a scoping review regarding the uses of abdominal non-radiologist point-of-care US, quality of examinations and training, patient perspective, financial costs and legal consequences following the use of non-radiologist point-of-care US. We conducted an advanced search of the following databases: Medline, Embase and Web of Science Conference Proceedings. We included published original research studies describing abdominal non-radiologist point-of-care US in children. We limited studies to English-language articles from Western countries. RESULTS We found a total of 5,092 publications and selected 106 publications for inclusion: 39 studies and 51 case reports or case series on the state-of-art of abdominal non-radiologist point-of-care US, 14 on training of non-radiologists, and 1 each on possible harms following non-radiologist point-of-care US and patient satisfaction. According to included studies, non-radiologist point-of-care US is increasingly used, but no standardised training guidelines exist. We found no studies regarding the financial consequences of non-radiologist point-of-care US. CONCLUSION This scoping review supports the further development of non-radiologist point-of-care US and underlines the need for consensus on who can do which examination after which level of training among US performers. More research is needed on training non-radiologists and on the costs-to-benefits of non-radiologist point-of-care US.
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Affiliation(s)
- Elsa A van Wassenaer
- Emma Children's Hospital, Amsterdam UMC, Paediatric Gastroenterology, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands. .,Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Amsterdam Gastroenterology and Metabolism,Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Joost G Daams
- Amsterdam UMC, Medical Library, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, Paediatric Gastroenterology, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Karen Rosendahl
- Department of Radiology, Section of Paediatric Radiology, University Hospital North Norway, Tromsø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Bart G P Koot
- Emma Children's Hospital, Amsterdam UMC, Paediatric Gastroenterology, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Samuel Stafrace
- Division of Body imaging, Department of Diagnostic Imaging, Sidra Medicine and Weill Cornell Medicine, Doha, Qatar
| | - Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,NIHR Great Ormond Street Biomedical Research Centre, London, UK
| | - Rick R van Rijn
- Amsterdam UMC, Radiology, University of Amsterdam, Amsterdam, The Netherlands
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Halm BM, Leone TA, Chaudoin LT, McKinley KW, Ruzal-Shapiro C, Franke AA, Tsze DS. Evaluation of Ventricle Size Measurements in Infants by Pediatric Emergency Medicine Physicians. Pediatr Emerg Care 2021; 37:77-81. [PMID: 29877908 DOI: 10.1097/pec.0000000000001497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The identification of hydrocephalus in infants by pediatric emergency medicine (PEM) physicians using cranial point-of-care ultrasound (POCUS) has not been evaluated. We aimed to conduct a pilot/proof-of-concept study to evaluate whether PEM physicians can identify hydrocephalus (anterior horn width >5 mm) in 15 infants (mean 69 ± 42 days old) from the neonatal intensive care unit using POCUS. Our exploratory aims were to determine the test characteristics of cranial POCUS performed by PEM physicians for diagnosing hydrocephalus and the interrater reliability between measurements made by the PEM physicians and the radiologist. METHODS Depending on the availability, 1 or 2 PEM physicians performed a cranial POCUS through the open anterior fontanel for each infant after a 30-minute didactic lecture to determine the size of the left and right ventricles by measuring the anterior horn width at the foramen of Monroe in coronal view. Within 1 week, an ultrasound (US) technologist performed a cranial US and a radiologist determined the ventricle sizes from the US images; these measurements were the criterion standard. RESULTS A radiologist determined 12 of the 30 ventricles as hydrocephalic. The sensitivity and specificity of the PEM physicians performed cranial POCUS was 66.7% (95% confidence interval [CI], 34.9%-90.1%) and 94.4% (95% CI, 72.7%-99.9%), whereas the positive and negative predictive values were 88.9% (95% CI, 53.3%-98.2%) and 81.0% (95% CI, 65.5%-90.5%), respectively. The interrater reliability between the PEM physician's and radiologist's measurements was r = 0.91. The entire POCUS examinations performed by the PEM physicians took an average of 1.5 minutes. The time between the cranial POCUS and the radiology US was, on average, 4 days. CONCLUSIONS While the PEM physicians in our study were able to determine the absence of hydrocephalus in infants with high specificity using cranial POCUS, there was insufficient evidence to support the use of this modality for identifying hydrocephalus. Future studies with more participants are warranted to accurately determine test characteristics.
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Affiliation(s)
| | | | | | | | - Carrie Ruzal-Shapiro
- Radiology, New York-Presbyterian Morgan Stanley Children's Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Adrian A Franke
- Cancer Biology, University of Hawaii Cancer Center, Honolulu, HI
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Abstract
OBJECTIVES The novel coronavirus disease 2019 (Covid-19) outbreak began in China. The characteristic of the disease is development of pneumonia. We aimed to investigate the accuracy of bedside lung ultrasound (BLUS) for diagnosing Covid-19 pneumonia, and its effectiveness for the correct triage of patients with suspected Covid-19 in the emergency department (ED). METHODS This study was a prospective, cross-sectional cohort study. During their shifts, 3 accredited and certificated emergency physicians performed BLUS using BLUE protocol at the triage area of the ED on patients with suspected Covid-19. All of the patients underwent chest computed tomography. The BLUS findings were statistically compared with formal radiology reports of computed tomographies as the criterion standard for the diagnosis of Covid-19 pneumonia. Kolmogorov-Smirnov analysis, Shapiro-Wilk test, and Q-Q plots were performed with 95% confidence intervals (CIs) for statistical analysis. RESULTS A total of 72 patients were included in the study. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of BLUS were 96.9% (95% CI, 84.2%-99.9%), 92.3% (95% CI, 79.1%-98.3%), 84.3% (95% CI, 64.5%-94.1%), 98.6% (95% CI, 91.1%-99.8%), and 93.7% (95% CI, 85.3%-98.0%), respectively. The positive and negative predictive values were 84.3% (95% CI, 64.5%-94.1%) and 98.6% (95% CI, 91.1%-99.8%), respectively. The area under curve was found to be 0.946 (95% CI, 0.866-0.986; P < 0.0001). CONCLUSIONS Bedside lung ultrasound can be used to detect the presence of pulmonary involvement in suspected cases of Covid-19 for the effective triage of patients in the ED.
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Point-of-Care Ultrasound Diagnosis of Perforated Appendicitis in the Pediatric Emergency Department: A Case Series. Pediatr Emerg Care 2020; 36:606-608. [PMID: 32195980 DOI: 10.1097/pec.0000000000002082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Point-of-care ultrasound (POCUS) is being used for clinical decision making with increasing frequency across a broad range of indications in pediatric emergency medicine (PEM). We present a series of 4 patients in whom POCUS was used to facilitate a diagnosis of perforated appendicitis.
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12
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Scheier E, Budde-Schwartzman B, Kartun V, Balla U. Identifying Retrocecal Appendicitis on Point-of-Care Ultrasound (POCUS). J Emerg Med 2020; 59:413-417. [PMID: 32571638 DOI: 10.1016/j.jemermed.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Retrocecal appendicitis may be challenging to find. We present the first case series in which retrocecal appendicitis was found on point-of-care ultrasound (POCUS). CASE REPORTS In each of the five cases, appendicitis was found by a pediatric emergency physician in the right periumbilical region or right upper quadrant. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The POCUS practitioner should scan both the right upper and right lower quadrant of the abdomen in search of appendicitis, as well as in search of signs of perforation.
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Affiliation(s)
- Eric Scheier
- Department of Pediatric Emergency Medicine, Rehovot, Israel
| | | | - Valery Kartun
- Department of Pediatric Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Uri Balla
- Department of Pediatric Emergency Medicine, Rehovot, Israel
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13
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Accuracy of ultrasound exam performed by emergency medicine versus radiology residents in the diagnosis of acute appendicitis. Eur J Emerg Med 2020; 26:272-276. [PMID: 29438133 DOI: 10.1097/mej.0000000000000547] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although the traditional approach to the diagnosis of acute appendicitis (AA) is using clinical methods, experience has shown that strict reliance on clinical data can lead to mismanagement or unnecessary surgery. OBJECTIVE The objective of this study was to determine the total agreement of ultrasound (US) results in AA performed by emergency medicine (EM) versus radiology residents in emergency department. PATIENTS AND METHODS In this cross-sectional study, 121 patients with AA suspicion underwent an US exam by both trained EM and radiology residents in emergency department. The training course for EM residents consisted of attending an 8-h-workshop and then practicing an US exam on real patients within a 2-month period. The gold standards were either histopathologic or follow-up results. Total agreement of the results in both specialties was compared. RESULTS There were 67 men and 54 women, with a mean age of 33.6 ± 16.1 years (18.2-88.7 years). Fifty-four (44.6%) patients underwent surgery with the initial diagnosis of AA and the rest were evaluated by follow-ups. On the basis of our gold standards, the diagnosis was finally confirmed in 46 (38%) cases. There was a high total agreement in AA diagnosis [96% agreement, κ = 0.90; 95% confidence interval (CI) = 0.81-0.99] between the two groups. The specificity and sensitivity of EM and radiology groups were 99% (95% CI = 93-100), 63% (95% CI = 48-77), 97% (95% CI = 91-100), and 72% (95% CI = 57-84), respectively. CONCLUSION US has a high diagnostic specificity in patients suspected of having AA and EM residents can perform this modality as accurately as radiologists after training in the emergency setting.
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14
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Shen G, Wang J, Fei F, Mao M, Mei Z. Bedside ultrasonography for acute appendicitis: An updated diagnostic meta-analysis. Int J Surg 2019; 70:1-9. [PMID: 31404675 DOI: 10.1016/j.ijsu.2019.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/28/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022]
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Coskun AK, Coskun ZY. A commentary on "bedside ultrasonography for acute appendicitis: An updated diagnostic meta-analysis" (Int J Surg 2019 Aug 9;70:1-9. doi: 10.1016/j.ijsu.2019.08.009. [Epub ahead of print]). Int J Surg 2019; 71:84. [PMID: 31561007 DOI: 10.1016/j.ijsu.2019.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Ali Kagan Coskun
- University of Health Sciences, Gulhane School of Medicine, Department of General Surgery, Ankara, Turkey.
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Point-of-care ultrasound diagnosis of stump appendicitis in the emergency department. Ultrasound J 2019; 11:12. [PMID: 31359172 PMCID: PMC6638604 DOI: 10.1186/s13089-019-0128-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/03/2019] [Indexed: 11/20/2022] Open
Abstract
Background Stump appendicitis (SA) is a rare entity in patients with a history of appendectomy and may result in missed or delayed diagnosis. We report a case of SA diagnosed by emergency department (ED) point-of-care ultrasound (PoCUS) in an elderly woman, thus expediting her care. Case presentation An elderly female patient with a history of appendectomy 27 years ago was referred by her physician to the ED with right lower quadrant pain for 2 days. Using PoCUS the emergency physician identified SA. This was confirmed by computed tomography (CT) scan. The patient was then successfully managed non-operatively using antibiotics. Conclusions Despite its rarity, it is feasible to diagnose SA using PoCUS, as patients presenting with right lower quadrant pain and history of appendectomy are at risk for delayed diagnosis, perforation, and poor outcome. PoCUS may reduce time to diagnosis, time to definitive operative or non-operative management, and minimize morbidity.
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Bourcier JE, Gallard E, Redonnet JP, Majourau M, Deshaie D, Bourgeois JM, Garnier D, Geeraerts T. Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain. Crit Ultrasound J 2018; 10:31. [PMID: 30467798 PMCID: PMC6250608 DOI: 10.1186/s13089-018-0112-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Background Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain. Methods This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient. Results From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p < 0.001). Conclusion Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.
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Affiliation(s)
- Jean-Eudes Bourcier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France.
| | - Emeric Gallard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Jean-Philippe Redonnet
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Magali Majourau
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Dominique Deshaie
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | | | - Didier Garnier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care Department, Toulouse University Hospital, University Toulouse III Paul Sabatier, Toulouse, France
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Kozaci N, Avci M, Tulubas G, Ararat E, Karakoyun OF, Karaman C, Erol B. Role of emergency physician–performed ultrasound in the differential diagnosis of abdominal pain. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918808115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objectives: This prospective study was performed to evaluate the diagnostic accuracy of bedside point-of-care abdominal ultrasonography performed by emergency physician in patients with non-traumatic acute abdominal pain. Methods: The patients, who were admitted to emergency department due to abdominal pain, were included in this study. The emergency physician obtained a routine history, physical examination, blood draws, and ordered diagnostic imaging. After the initial clinical examinations, all the patients underwent ultrasonography for abdominal pathologies by emergency physician and radiologist, respectively. Point-of-care abdominal ultrasonography compared with abdominal ultrasonography performed by radiologist as the gold standard. Results: The study included 122 patients. Gallbladder and appendix pathologies were the most commonly detected in the abdominal ultrasonography. Compared with abdominal ultrasonography, point-of-care abdominal ultrasonography was found to have 89% sensitivity and 94% specificity in gallbladder pathologies; 91% sensitivity and 91% specificity in acute appendicitis; 79% sensitivity and 97% specificity in abdominal free fluid; 83% sensitivity and 96% specificity in ovarian pathologies. Compared to final diagnosis, preliminary diagnoses of emergency physicians were correct in 92 (75.4%) patients. Conclusion: This study showed that emergency physicians were successful in identifying abdominal organ pathologies with point-of-care abdominal ultrasonography after training.
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Affiliation(s)
- Nalan Kozaci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Mustafa Avci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Gul Tulubas
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ertan Ararat
- Department of Emergency Medicine, Uşak University Education and Research Hospital, Uşak, Turkey
| | - Omer Faruk Karakoyun
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Cagri Karaman
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Bekir Erol
- Department of Radiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
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Nicole M, Desjardins MP, Gravel J. Bedside Sonography Performed by Emergency Physicians to Detect Appendicitis in Children. Acad Emerg Med 2018; 25:1035-1041. [PMID: 29738103 DOI: 10.1111/acem.13445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the ability of emergency physicians with various levels of point-of-care ultrasound (POCUS) experience to detect appendicitis with POCUS among children visiting a pediatric emergency department (ED). METHODS A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy or hemodynamic instability requiring resuscitation or were transferred with proven diagnosis of appendicitis. Participating physicians had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography while the others had basic experience in abdominal POCUS. All the participating physicians received a 1-hour didactic and practical training session on appendix ultrasound. The treating physician performed POCUS following initial physical examination, before further radiologic evaluation. POCUS examinations were recorded as positive for appendicitis, normal, or inconclusive, with normal or inconclusive studies considered negative. Final outcomes were determined by pathology and/or operative reports for surgical cases and telephone follow-up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95% confidence interval (CI) ranging from 66% to 90%. RESULTS Of the 140 approached patients, 121 accepted to participate and were recruited. After four patients were excluded for missing POCUS data, 117 patients were included in the primary analysis, of whom 51 (44%) had appendicitis. Twenty-two physicians performed between one and 20 POCUS procedures. The POCUS was positive in 39, negative in nine, and inconclusive in 69 patients. POCUS was interpreted as positive in 27 of 51 appendicitis for a sensitivity of 0.53 (95% CI = 0.40-0.66). A negative or inconclusive POCUS was reported for 54 of 66 patients without appendicitis (specificity = 0.82; 95% CI = 0.71-0.89). CONCLUSION This study shows limited sensitivity and specificity of POCUS for appendicitis in children, with a high proportion of inconclusive examinations, when performed by emergency physicians with various level of experience in POCUS.
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Affiliation(s)
- Marie Nicole
- Emergency Department Hôpital du Sacré‐Coeur de Montréal Montréal QuébecCanada
| | | | - Jocelyn Gravel
- Emergency Department CHU Ste‐Justine Montréal Québec Canada
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Lee SH, Yun SJ. Diagnostic performance of emergency physician-performed point-of-care ultrasonography for acute appendicitis: A meta-analysis. Am J Emerg Med 2018; 37:696-705. [PMID: 30017693 DOI: 10.1016/j.ajem.2018.07.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/11/2018] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To assess the sensitivity and specificity of emergency physician-performed point-of-care ultrasonography (EP-POCUS) for diagnosing acute appendicitis (AA). MATERIAL AND METHODS The PubMed and EMBASE databases were searched, and the diagnostic performance of EP-POCUS was evaluated using bivariate modeling and hierarchical summary receiver operating characteristic curves. Subgroup analysis was performed for pediatric patients to compare EP-POCUS and radiologist-performed ultrasonography (RADUS). Meta-regression analyses were performed according to patient and study characteristics. RESULTS In 17 studies (2385 patients), EP-POCUS for diagnosing AA exhibited a pooled sensitivity of 84% (95% confidence interval [CI]: 72%-92%) and a pooled specificity of 91% (95% CI: 85%-95%), with even better diagnostic performance for pediatric AA (sensitivity: 95%, 95% CI: 75%-99%; specificity: 95%, 95% CI: 85%-98%). A direct comparison revealed no significant differences (p = 0.18-0.85) between the diagnostic performances of EP-POCUS (sensitivity: 81%, 95% CI: 61%-90%; specificity: 89%, 95% CI: 77%-95%) and RADUS (sensitivity: 74%, 95% CI: 65%-81%; specificity: 97%, 95% CI: 93%-98%). The meta-regression analyses revealed that study location, AA proportion, and mean age were sources of heterogeneity. Higher sensitivity and specificity tended to be associated with an appendix diameter cut-off value of 7 mm and the EP as the initial operator. CONCLUSION The diagnostic performances of EP-POCUS and RADUS were excellent for AA, with EP-POCUS having even better performance for pediatric AA. Accurate diagnoses may be achieved when the attending EP is the initial POCUS operator and uses a 7-mm cut-off value.
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Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul, 01757, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, Republic of Korea.
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Kim J, Kim K, Kim J, Yoo J, Jeong W, Cho S, Joo K, Cho Y, Lee J, Ryu S, Yoo Y. The learning curve in diagnosing acute appendicitis with emergency sonography among novice emergency medicine residents. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:305-310. [PMID: 29315613 DOI: 10.1002/jcu.22577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 11/25/2017] [Accepted: 12/21/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Ultrasonography (US) has good accuracy for diagnosing appendicitis when it is performed by emergency physicians. This study aimed to determine the amount of experience that is required to achieve competency in this field. METHODS Three novice emergency medicine residents completed a 1-day training course regarding the US diagnosis of appendicitis. Then, they performed appendix US in the emergency department on patients complaining of right lower quadrant pain. All included patients also underwent computed tomography or US performed by a board-certified radiologist, to confirm the emergency US diagnosis. The agreement between the diagnoses of novices and experts was evaluated. RESULTS A total of 266 patients were included, and the overall Cohen's kappa coefficient was 0.77 (95% confidence interval [CI]: 0.69-0.84). The kappa value of first 20 cases was 0.49 (95% CI: 0.27-0.71). It increased rapidly during evaluation of the first 20 cases. After the first 20 cases, the kappa coefficient was 0.84 (95% CI: 0.77-0.92). The sensitivity and specificity values for the first 20 cases were 64.3% (95% CI: 77.6%-90.7%) and 84.4% (95% CI: 85.4%-95.4%), respectively. After the first 20 cases, the sensitivity and specificity values increased to 90.9% (95% CI: 83.4%-95.8%) and 93.5% (95% CI: 87.0%-97.3%), respectively. CONCLUSIONS A minimum of 20 cases are needed to achieve competency in emergency US diagnosis of acute appendicitis.
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Affiliation(s)
- Jeehyun Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Kipum Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jungwan Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jungwoo Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sunguk Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Kihyuk Joo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yongchul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jinwoong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yeonho Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
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Corson-Knowles D, Russell FM. Clinical Ultrasound Is Safe and Highly Specific for Acute Appendicitis in Moderate to High Pre-test Probability Patients. West J Emerg Med 2018; 19:460-464. [PMID: 29760840 PMCID: PMC5942008 DOI: 10.5811/westjem.2018.1.36891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/04/2018] [Accepted: 01/23/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. Methods This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. Results We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25–62.5%]), 97.9% (95% CI [87.5–99.8%]), 20.7 (95% CI [2.8–149.9]) and 0.58 (95% CI [0.42–0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. Conclusion A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.
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Affiliation(s)
- Daniel Corson-Knowles
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
| | - Frances M Russell
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
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Abstract
OBJECTIVES We hypothesized that point-of-care ultrasound (POCUS) is as accurate as radiology-performed ultrasound in evaluating children with clinical concern for appendicitis. As part of a staged approach, we further hypothesized that POCUS could ultimately decrease computed tomography (CT) utilization. METHODS This was a prospective, convenience sampling of patients aged 2 to 18 years presenting with abdominal pain to a pediatric emergency department. Those patients with prior abdominal imaging, pregnant, or unable to tolerate the examination were excluded. An algorithm was followed: POCUS was first performed, followed by a radiology-performed ultrasound, and then a CT as necessary. The main outcome measure was the accuracy of the POCUS in diagnosing of appendicitis. This was compared with radiology-performed ultrasound. We also examined whether certain patient or clinical characteristics influenced the performance of POCUS. Lastly, we determined the amount by which CT scans were decreased through this staged algorithm. RESULTS Forty patients were enrolled and underwent a POCUS examination. A total of 16 (40%) had pathology-confirmed appendicitis. Point-of-care ultrasound had a sensitivity of 93.8% (95% confidence interval [CI], 69.7%-98.9%) and specificity of 87.5% (95% CI, 67.6%-97.2%). Radiology-performed ultrasound had a sensitivity of 81.25% (95% CI, 54.3%-95.7%) and specificity of 100% (95% CI, 85.6%-100%). The radiology-performed and POCUS examinations had very good agreement (κ = 0.83, P < 0.0005). Patient characteristics including body mass index did not have an affect on the POCUS. However, POCUS identified all patients with an Alvarado score higher than 6. Overall, the reduction in CT examinations was 55%. CONCLUSIONS In pediatric patients presenting with clinical concern for acute appendicitis, a staged algorithm that incorporates POCUS is accurate and has the potential to decrease CT scan utilization.
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Unluer EE, Karagoz A, Senturk GO, Karaman M, Olow KH, Bayata S. Bedside lung ultrasonography for diagnosis of pneumonia. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791302000205] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The aim of this study was to investigate the accuracy of bedside lung ultrasound (BUS) in the diagnosis of community-acquired pneumonia (CAP) in patients with dyspnoea presenting to the emergency department (ED) and to analyse the characteristic sonographic findings of CAP. Methods After a six-hour training program, BUS procedures were performed between October 2011 and February 2012 to prospectively evaluate patients presenting to the ED with dyspnoea. Chest X-ray (CXR) or computerised tomography (CT) were ordered, depending on the presence of consolidation signs on CXR. The outcome was determined by consolidation findings on CXR or CT. BUS results were compared using Chi-squared testing. Results Of the 112 enrolled patients with dyspnoea, 40 patients were excluded and 72 were included in the study. Thirty-four patients were BUS positive. Of these, CXR or CT findings agreed with the BUS findings in 27 patients. In 38 cases, BUS was negative, and one patient was diagnosed with pneumonia based on the CT report. The sensitivity, specificity, PPV, NPV, and the positive and negative likelihood ratios for BUS were 96.4%, 84.1%, 79.4%, 97.4%, 6.1 and 0.042, respectively. The diagnostic accuracy of BUS was 89%. The presence of consolidation signs, either shred or hepatisation, were the most frequent sonographic findings in our study. Conclusions Acute alveolar consolidation can be diagnosed easily by performing BUS with high degree of accuracy in EDs.
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Affiliation(s)
| | | | | | | | - KH Olow
- Benadir University, Faculty of Medicine and Surgery, Mogadishu/Somalia
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Matthew Fields J, Davis J, Alsup C, Bates A, Au A, Adhikari S, Farrell I. Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:1124-1136. [PMID: 28464459 DOI: 10.1111/acem.13212] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/31/2017] [Accepted: 04/07/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of ultrasonography (US) to diagnose appendicitis is well established. More recently, point-of-care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study was through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically US performed by a nonradiologist physician, in accurately diagnosing acute appendicitis in patients of any age. METHODS We conducted a thorough and systematic literature search of English language articles published on point-of-care, physician-performed transabdominal US used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID MEDLINE In-Process & Other Non-indexed Citations and Scopus. Studies were selected and subsequently independently abstracted by two trained reviewers. A random-effects pooled analysis was used to construct a hierarchical summary receiver operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool. RESULTS Our search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range = 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis were 91% (95% confidence interval [CI] = 83%-96%) and 97% (95% CI = 91%-99%), respectively. The positive and negative predictive values were 91 and 94%, respectively. Studies performed by emergency physicians had slightly lower test characteristics (sensitivity = 80%, specificity = 92%). There was significant heterogeneity between studies (I2 = 99%, 95% CI = 99%-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators were variably reported. CONCLUSION Point-of-care US has relatively high sensitivity and specificity for diagnosing acute appendicitis, although the data presented are limited by the quality of the original studies and large CIs. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a stand-alone test or to rule out appendicitis.
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Affiliation(s)
- J. Matthew Fields
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Joshua Davis
- Department of Emergency Medicine; Penn State Milton S. Hershey Medical Center; Hershey PA
| | - Carl Alsup
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Arthur Au
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Isaac Farrell
- The University of Arizona College of Medicine; Tucson AZ
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Badru F, Piening N, To A, Xu P, Fitzpatrick C, Chatoorgoon K, Villalona G, Greenspon J. Imaging for acute appendicitis at nonpediatric centers exposes children to excess radiation. J Surg Res 2017; 216:201-206. [DOI: 10.1016/j.jss.2017.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 04/04/2017] [Accepted: 04/27/2017] [Indexed: 12/29/2022]
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What Elements of the History, Examination, Laboratory Testing, or Point-of-Care Ultrasonography Are Most Useful in the Diagnosis of Acute Appendicitis in Children? Ann Emerg Med 2017; 70:797-798. [PMID: 28662913 DOI: 10.1016/j.annemergmed.2017.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 11/23/2022]
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Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:523-551. [PMID: 28214369 DOI: 10.1111/acem.13181] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/17/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. OBJECTIVES The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). METHODS We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. RESULTS Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. CONCLUSION Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Mark Hanna
- Department of Pediatrics; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Pediatrics; Kings County Hospital Center; Brooklyn NY
| | - Jay Shah
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
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Gungor F, Kilic T, Akyol KC, Ayaz G, Cakir UC, Akcimen M, Eken C. Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department. Acad Emerg Med 2017; 24:578-586. [PMID: 28171688 DOI: 10.1111/acem.13169] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 01/28/2017] [Accepted: 01/29/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED). METHODS The study sample consisted of patients aged > 18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared. RESULTS A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000). CONCLUSION Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.
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Affiliation(s)
- Faruk Gungor
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Taylan Kilic
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Kamil Can Akyol
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Gizem Ayaz
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Umut Cengiz Cakir
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Mehmet Akcimen
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Cenker Eken
- Department of Emergency Medicine; Akdeniz University Medical Faculty; Antalya Turkey
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Allen B, Carrol LV, Hughes DR, Hemingway J, Duszak R, Rosenkrantz AB. Downstream Imaging Utilization After Emergency Department Ultrasound Interpreted by Radiologists Versus Nonradiologists: A Medicare Claims–Based Study. J Am Coll Radiol 2017; 14:475-481. [DOI: 10.1016/j.jacr.2016.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 12/16/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
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Kartal ZA, Kozacı N, Çekiç B, Beydilli İ, Akçimen M, Güven DS, Toslak İE. CT interpretations in multiply injured patients: comparison of emergency physicians and on-call radiologists. Am J Emerg Med 2016; 34:2331-2335. [DOI: 10.1016/j.ajem.2016.08.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 10/21/2022] Open
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care 2016; 4:53. [PMID: 27529029 PMCID: PMC4983797 DOI: 10.1186/s40560-016-0175-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 07/12/2016] [Indexed: 01/16/2023] Open
Abstract
Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.
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Affiliation(s)
- Toru Kameda
- Department of Emergency Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8292 Japan
| | - Nobuyuki Taniguchi
- Department of Clinical Laboratory Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
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Lam SHF, Kerwin C, Konicki PJ, Goodwine D, Lambert MJ. Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy. West J Emerg Med 2016; 17:454-9. [PMID: 27429696 PMCID: PMC4944802 DOI: 10.5811/westjem.2016.5.29681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/02/2016] [Accepted: 05/05/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction The objective of this study was to determine whether there is a relationship between body mass index (BMI) and success or accuracy rate of beside ultrasound (BUS) for the diagnosis of appendicitis. Methods Patients four years of age and older presenting to the emergency department with suspected appendicitis were eligible. Enrollment was by convenience sampling. After informed consent, BUS was performed by trained emergency physicians who had undergone a minimum of one-hour didactic training on the use of BUS to diagnose appendicitis. We ascertained subject outcomes by a combination of medical record review and telephone follow up. Calculated BMI for adults and children were divided into four categories (underweight, normal, overweight, obese) according to Centers for Disease Control and Prevention classifications. Results A total of 125 subjects consented for the study, and 116 of them had adequate image data for final analysis. Seventy (60%) of the subjects were children. Prevalence of appendicitis was 39%. Fifty-two (45%) of the BUS studies were diagnostic (successful). Overall accuracy rate was 75%. Analysis by chi-square test or Mann-Whitney U test did not find any significant correlation between BMI category and BUS success. Similarly, there was no significant correlation between BMI category and BUS accuracy. The same conclusion was reached when children and adults were analyzed separately, or when subjects were dichotomized into underweight/normal and overweight/obese categories. Conclusion BMI category alone is a poor predictor of appendix BUS success or accuracy.
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Affiliation(s)
- Samuel H F Lam
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Christopher Kerwin
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - P John Konicki
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Diana Goodwine
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Michael J Lambert
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
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Ünlüer EE, Urnal R, Eser U, Bilgin S, Hacıyanlı M, Oyar O, Akoğlu H, Karagöz A. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis. World J Emerg Med 2016; 7:124-9. [PMID: 27313807 DOI: 10.5847/wjem.j.1920-8642.2016.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis. METHODS Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital. RESULTS The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis. CONCLUSION BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.
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Affiliation(s)
- Erden Erol Ünlüer
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Rıfat Urnal
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Utku Eser
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Serkan Bilgin
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Mehmet Hacıyanlı
- Department of General Surgery, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Orhan Oyar
- Department of Radiology, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Haldun Akoğlu
- Department of Emergency Medicine, Faculty of Medicine, Marmara University, İstanbul, İstanbul 34890, Turkey
| | - Arif Karagöz
- Department of Emergency Medicine, Karşıyaka State Hospital, Karşıyaka, İzmir 35520, Turkey
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Marin JR, Lewiss RE. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med 2016; 65:472-8. [PMID: 25805037 DOI: 10.1016/j.annemergmed.2015.01.028] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.
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Abstract
We present two cases of pediatric patients initially presenting with a clinical suspicion of acute appendicitis. In these cases, point-of-care ultrasonography was performed early in the patient's emergency department course, leading to alternate diagnoses. This article highlights a role for point-of-care ultrasound in the diagnoses of two alternate conditions that clinically mimic appendicitis: Meckel diverticulitis and acute ileocecitis. We offer a brief overview of terminology, relevant literature, and ultrasound scanning technique for the right-lower-quadrant point-of-care ultrasound evaluation.
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Pare JR, Langlois BK, Scalera SA, Husain LF, Douriez C, Chiu H, Carmody K. Revival of the use of ultrasound in screening for appendicitis in young adult men. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:3-11. [PMID: 26178008 DOI: 10.1002/jcu.22282] [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: 11/21/2014] [Revised: 04/28/2015] [Accepted: 05/10/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE Our primary aim was to evaluate the use of ultrasound (US) as an initial screening test for diagnosing appendicitis in young adult men. Secondary exploratory analyses included the effects of using US for initial screening in these patients, compared with the use of CT, on radiation exposure, length of stay (LOS), and cost of imaging. METHODS We retrospectively gathered data from the records of male patients 18-39 years old who had been admitted with appendicitis between June 2006 and September 2011. We investigated the diagnostic tests performed, the patients' characteristics, and the pathologic testing findings and compared the results obtained on US with those obtained on CT. RESULTS Of 451 included patients, 86 had undergone US initially. Its sensitivity was only 57% (95% confidence interval, 46-67.6), but its positive predictive value was 98% (95% confidence interval, 93.8-100). The mean LOS was significantly shorter for patients who had undergone US only (214 minutes) than it was for those who had undergone CT only (276 minutes; p < 0.001). We estimated a 57% reduction in CT use and radiation exposure if US were to be performed initially; this would lead to a 45% decrease in imaging costs at our institution. CONCLUSIONS Screening US should be considered first for diagnosing appendicitis because of its high positive predictive value, but even if US results are negative for appendicitis, one should not exclude the possible existence of pathology because US has poor sensitivity in this situation. We speculate that the use of screening US can decrease radiation exposure, imaging costs, and LOS.
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Affiliation(s)
- Joseph R Pare
- Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, 464 Congress Avenue, Suite 260, New Haven, CT, 06519
| | - Breanne K Langlois
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118
| | - Sushama A Scalera
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118
| | - Lubna Farooq Husain
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118
| | - Carole Douriez
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118
| | - Helen Chiu
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118
| | - Kristin Carmody
- Department of Emergency Medicine, NY University School of Medicine, NYU Langone Medical Center/Bellevue Hospital Center, First Avenue & 27th Street, Room A340, New York, NY, 10016
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The Use of Point-of-Care Ultrasound to Evaluate for Intestinal Foreign Bodies in the Pediatric Emergency Department. Pediatr Emerg Care 2015; 31:731-4. [PMID: 26427951 DOI: 10.1097/pec.0000000000000569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We present the use of point-of-care ultrasound to evaluate two patients with examinations concerning for appendicitis who were found to have multiple magnets ingested and subsequent bowel perforations. These cases illustrate the consequences of magnet ingestion as well as the application of point-of-care ultrasound for the identification of intestinal foreign bodies in children.
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Dickman E, Tessaro MO, Arroyo AC, Haines LE, Marshall JP. Clinician-performed abdominal sonography. Eur J Trauma Emerg Surg 2015; 41:481-92. [PMID: 26038027 DOI: 10.1007/s00068-015-0508-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 03/02/2015] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions. METHODS A literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies. CONCLUSION Clinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.
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Affiliation(s)
- E Dickman
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA.
| | - M O Tessaro
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, M5G1X8, Canada
| | - A C Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - L E Haines
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - J P Marshall
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
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Hasani SA, Fathi M, Daadpey M, Zare MA, Tavakoli N, Abbasi S. Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study. Clin Imaging 2015; 39:476-9. [PMID: 25667065 DOI: 10.1016/j.clinimag.2015.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Abdominal pain is a common complaint in the emergency department and accurate diagnosis of its etiology may affect the patient's outcome. METHOD Patients with abdominal pain underwent ultrasound study first by trained emergency physicians and then by radiologists blinded to emergency physician's results. RESULT Emergency physician who performed bedside ultrasound had 78% diagnostic accuracy. Emergency physicians showed better results in diagnosing some entities (abdominal aortic aneurysm and renal stones) than the others (acute appendicitis, cholelithiasis, and cholecystitis). CONCLUSION Bedside ultrasound can accurately identify the etiology of acute nontraumatic abdominal pain in the hands of emergency physicians.
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Affiliation(s)
| | - Marzieh Fathi
- Emergency Department, Iran University of Medical Sciences (IUMS).
| | - Marzieh Daadpey
- Emergency Department, Iran University of Medical Sciences (IUMS)
| | | | - Nader Tavakoli
- Emergency Department, Iran University of Medical Sciences (IUMS)
| | - Saeed Abbasi
- Emergency Department, Iran University of Medical Sciences (IUMS)
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Canders CP, Brown AJ, Chiem AT. False positive appendicitis on bedside ultrasound. West J Emerg Med 2014; 15:832-3. [PMID: 25493128 PMCID: PMC4251229 DOI: 10.5811/westjem.2014.9.23550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 08/21/2014] [Accepted: 09/23/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Caleb P Canders
- University of California at Los Angeles Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Angela J Brown
- University of California at Los Angeles Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Alan T Chiem
- Olive View - University of California at Los Angeles Medical Center, Department of Emergency Medicine, Sylmar, California
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Mallin M, Craven P, Ockerse P, Steenblik J, Forbes B, Boehm K, Youngquist S. Diagnosis of appendicitis by bedside ultrasound in the ED. Am J Emerg Med 2014; 33:430-2. [PMID: 25559314 DOI: 10.1016/j.ajem.2014.10.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/06/2014] [Accepted: 10/06/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Computed tomography (CT) has largely become standard of care for diagnosing appendicitis at the expense of increased patient radiation exposure, cost, and time to surgical intervention. To date, there are very limited data on the accuracy of bedside ultrasound (BUS) for the diagnosis of appendicitis in adults. OBJECTIVE The objective of this study is to evaluate test characteristics of BUS for diagnosis of acute appendicitis in the emergency department. METHODS Data were prospectively collected on 97 cases of suspected appendicitis, which had BUS performed by trained residents with attending supervision between August 2011 and November 2013. All BUS interpretation and additional diagnostic imaging were left to the discretion of the physician or surgical consultants. A blinded ultrasound fellowship-trained physician reviewed all images after clinical treatment. Bedside ultrasound findings and patient outcomes were reported. RESULTS A total of 97 adult cases underwent diagnostic ultrasound scans for suspected appendicitis. Of 97 cases, 34 had acute appendicitis by surgery/pathology report. Twenty-four BUS were positive for acute appendicitis and 11 were nondiagnostic. Of 24 positive ultrasounds, 23 had appendicitis on pathology report. There was 1 false-positive result, yielding a sensitivity of 67.65% (95% confidence limits, 49.5%-82.6%) and a specificity of 98.41% (95% confidence limits, 91.4%-99.7%). Of 23 positive BUS, 12 cases went to the Operating Room without an abdominal CT yielding a 12% reduction in CT utilization. If all positive BUS went to the OR without a CT scan, this would yield a 24% reduction in CT utilization. CONCLUSIONS Bedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department.
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Lam SHF, Grippo A, Kerwin C, Konicki PJ, Goodwine D, Lambert MJ. Bedside ultrasonography as an adjunct to routine evaluation of acute appendicitis in the emergency department. West J Emerg Med 2014; 15:808-15. [PMID: 25493122 PMCID: PMC4251223 DOI: 10.5811/westjem.2014.9.21491] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 06/09/2014] [Accepted: 09/02/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Appendicitis is a common condition presenting to the emergency department (ED). Increasingly emergency physicians (EP) are using bedside ultrasound (BUS) as an adjunct diagnostic tool. Our objective is to investigate the test characteristics of BUS for the diagnosis of appendicitis and identify components of routine ED workup and BUS associated with the presence of appendicitis. Methods Patients four years of age and older presenting to the ED with suspected appendicitis were eligible for enrollment. After informed consent was obtained, BUS was performed on the subjects by trained EPs who had undergone a minimum of one-hour didactic training on the use of BUS to diagnose appendicitis. They then recorded elements of clinical history, physical examination, white blood cell count (WBC) with polymophonuclear percentage (PMN), and BUS findings on a data form. We ascertained subject outcomes by a combination of medical record review and telephone follow-up. Results A total of 125 subjects consented for the study, and 116 had adequate image data for final analysis. Prevalence of appendicitis was 40%. Mean age of the subjects was 20.2 years, and 51% were male. BUS was 100% sensitive (95% CI 87–100%) and 32% specific (95% CI 14–57%) for detection of appendicitis, with a positive predictive value of 72% (95% CI 56–84%), and a negative predictive value of 100% (95% CI 52–100%). Assuming all non-diagnostic studies were negative would yield a sensitivity of 72% and specificity of 81%. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, vomiting, and a higher WBC and PMN count when compared to those without appendicitis. Their BUS studies were significantly more likely to result in visualization of the appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid, visualization of the appendix tip, and sonographic Mcburney’s sign (p<0.05). In subjects with diagnostic BUS studies, WBC, PMN, visualization of appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid were found to be predictors of appendicitis on logistic regression. Conclusion BUS is moderately useful for appendicitis diagnosis. We also identified several components in routine ED workup and BUS that are associated with appendicitis generating hypothesis for future studies.
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Affiliation(s)
- Samuel H F Lam
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Anthony Grippo
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Chistopher Kerwin
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - P John Konicki
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Diana Goodwine
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Michael J Lambert
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
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Fathi M, Hasani SA, Zare MA, Daadpey M, Hojati Firoozabadi N, Lotfi D. Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study. J Ultrasound 2014; 18:57-62. [PMID: 25767641 DOI: 10.1007/s40477-014-0130-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/23/2014] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis. METHODS Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes. RESULTS Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis. CONCLUSION Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.
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Affiliation(s)
- Marzieh Fathi
- Rasoul Akram Hospital, Iran University of Medical Sciences, Niyayesh St, Sattarkhan Ave, 14456 Tehran, Iran
| | - Seyyed Abbas Hasani
- Emergency Medicine Department, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Zare
- Emergency Medicine Department, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Daadpey
- Emergency Medicine Resident, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Hojati Firoozabadi
- Emergency Medicine Resident, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Daniyal Lotfi
- Emergency Medicine Resident, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Hayden GE, Russell WS, Park DB, Presley BC. Perforated appendicitis diagnosed at the bedside. J Emerg Med 2014; 47:e85-e88. [PMID: 24928542 DOI: 10.1016/j.jemermed.2014.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/24/2014] [Accepted: 04/28/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Geoffrey E Hayden
- Department of Medicine, Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - W Scott Russell
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel B Park
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley C Presley
- Department of Medicine, Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
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Abstract
PURPOSE OF REVIEW Point-of-care ultrasound (POCUS) has become an integral part of emergency medicine practice. Research evaluating POCUS in the care of pediatric patients has improved the understanding of its potential role in clinical care. RECENT FINDINGS Recent work has investigated the ability of pediatric emergency medicine (PEM) physicians to perform a wide array of diagnostic and procedural applications in POCUS ultrasound. Studies have demonstrated that PEM providers are able to identify an array of diseases, including intussusception, pyloric stenosis and appendicitis. Novel applications of ultrasound, such as a cardiac evaluation in the acutely ill patient or identification of skull fractures in the assessment of a patient with head injury, have shown excellent promise in recent studies. These novel applications have the potential to reshape pediatric diagnostic algorithms. SUMMARY Key applications in PEM have been investigated in the recent publications. Further exploration of the ability to integrate ultrasound into routine practice will require larger-scale studies and continued growth of education in the field. The use of ultrasound in clinical practice has the potential to improve safety and efficiency of care in the pediatric emergency department.
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Sivitz AB, Cohen SG, Tejani C. Evaluation of acute appendicitis by pediatric emergency physician sonography. Ann Emerg Med 2014; 64:358-364.e4. [PMID: 24882665 DOI: 10.1016/j.annemergmed.2014.03.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 03/13/2014] [Accepted: 03/28/2014] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE We investigate the accuracy of pediatric emergency physician sonography for acute appendicitis in children. METHODS We prospectively enrolled children requiring surgical or radiology consultation for suspected acute appendicitis at an urban pediatric emergency department. Pediatric emergency physicians performed focused right lower-quadrant sonography after didactics and hands-on training with a structured scanning algorithm, including the graded-compression technique. We compared their sonographic interpretations with clinical and radiologic findings, as well as clinical outcomes as defined by follow-up or pathologic findings. RESULTS Thirteen pediatric emergency medicine sonographers performed 264 ultrasonographic studies, including 85 (32%) in children with pathology-verified appendicitis. Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75% to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of 11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to 0.28). CONCLUSION With focused ultrasonographic training, pediatric emergency physicians can diagnose acute appendicitis with substantial accuracy.
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Affiliation(s)
- Adam B Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Children's Hospital of New Jersey, Newark, NJ.
| | - Stephanie G Cohen
- Department of Pediatric Emergency Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Cena Tejani
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Children's Hospital of New Jersey, Newark, NJ
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Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med 2014; 21:163-70. [PMID: 24673672 DOI: 10.1111/acem.12319] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/29/2013] [Accepted: 09/11/2013] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization. METHODS This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities. RESULTS Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5). CONCLUSIONS It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.
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Affiliation(s)
- Inna Elikashvili
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
| | - Ee Tein Tay
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
- Emergency Ultrasound; Mount Sinai School of Medicine; New York NY
| | - James W. Tsung
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
- Emergency Ultrasound; Mount Sinai School of Medicine; New York NY
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Algaba-Montes M, Oviedo-García A, Nuñez-Hospital D, Lopez-Libano J, Alvarez-Franco JM, Diaz-Rodriguez N, Rodriguez-Lorenzo A. Emphysematous cholecystitis. Advantages of abdominal ultrasound in the ED. Crit Ultrasound J 2014. [PMCID: PMC4101563 DOI: 10.1186/2036-7902-6-s1-a7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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