Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm

Enhancing clinical outcomes: Point of care ultrasound in the precision diagnosis and Management of Abdominal Aortic Aneurysms in emergency medicine: A systematic review and meta-analysis

This meta-analysis evaluates the efficacy of point-of-care ultrasound (POCUS) in diagnosing abdominal aortic aneurysm (AAA) in the emergency department (ED). A systematic search of PubMed, Cochrane Library, Scopus, and Google Scholar identified studies published until July 2024. Nine studies were included, revealing that POCUS is highly accurate in diagnosing AAA, with a pooled sensitivity of 98.33% and specificity of 99.84%. Additionally, data from three studies indicated that 24.5% of patients with positive AAA scans were diagnosed with ruptured AAAs. The results suggest that emergency physicians can accurately detect and manage AAA using POCUS, even with limited training.

Initial signs in patients with ruptured abdominal aortic aneurysms: time for an expanded triad?

BACKGROUND AND OBJECTIVE

Misdiagnosis of ruptured abdominal aortic aneurysms (rAAA) contributes to delayed treatment and potentially higher mortality. The symptomatology in patients with rAAA is complex and challenging, 25-50% presumably fulfill the criteria of the standard triad of signs (STS). The objective was to determine the initial signs registered for patients with verified rAAAs, and to investigate if an expanded diagnostic triad could increase the diagnostic accuracy.

METHODS

A population-based study was conducted among all patients presenting with verified rAAAs in Stockholm County, Sweden, from January 2010 to October 2021. Patients were identified with ICD code 171.3 (rAAA). The STS was defined as (1) abdominal pain, (2) syncope and (3) the finding of a pulsatile abdominal mass, the prevalence of STS was investigated. An expanded triad included similar and related signs commonly registered for patients with rAAA, and was referred to as the modified abdominal aortic aneurysm rupture signs (MARS). The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding, and the prevalence was similarly investigated. Finally, the STS and MARS were compared to evaluate the usefulness and performance of the MARS-score.

RESULTS

A total of 216 patients were identified. The majority were men (77%) with a median age of 78 years. The dominating symptom was abdominal pain (84%), followed by dizziness (50%). Few patients presented with three STS (13%), two STS were found in 37% and one STS in almost half of the patients (41%). By contrast, when applying MARS 35% presented with the complete expanded triad, 47% with two and 17% with one. Comparison of accuracy favored MARS (13 vs. 35% with 3 signs, P < 0.001 for STS vs. MARS) (2 or 3 signs, 48 vs. 82% STS vs. MARS, P < 0.001).

CONCLUSIONS

The expanded MARS-signs could aid in easier and faster identification of rAAA patients, thus facilitating the first step with accurate diagnosis into the lifesaving rAAA care chain. Supportive diagnostic mnemonics and tools are especially important when targeting fatal diagnoses such as rAAA. Further studies are needed to investigate the implementation of the MARS-signs in various clinical settings.

Diagnostic accuracy of Point Of Care UltraSound (POCUS) in clinical practice: A retrospective, emergency department based study

AIMS

Point-of-care ultrasound (POCUS) is the acquisition and interpretation of ultrasound imaging at the bedside to solve specific clinical questions based on signs and symptoms of presentation. While several studies evaluated POCUS diagnostic accuracy for a variety of clinical pictures in the emergency department (ED), only a few data are available on POCUS diagnostic accuracy performed by physicians with different POCUS skills. The objective of this research was to evaluate the diagnostic accuracy of POCUS compared to standard diagnostic imaging in the ED.

MATERIALS AND METHODS

This was a retrospective study conducted in the ED of a third-level university hospital. Patients who underwent cardiac, thoracic, abdominal, or venous lower limb POCUS and a standard imaging examination between June 2021 and January 2022 were included.

RESULTS

1047 patients were screened, and 844 patients included. A total of 933 POCUS was included (102, 12.09%, cardiac; 466, 55.21%, thoracic; 336, 39.8%, abdominal; 29, 3.44%, lower limb venous POCUS), accounting for 2029 examinations. POCUS demonstrated 96.6% (95% CI 95.72-97.34) accuracy, 47.73 (95% CI 33.64-67.72) +LR, 0.09 (95% CI 0.06-0.12) -LR. +LR was greater than 10 for all investigations but for hydronephrosis (5.8), and -LR never exceeded 0.4.

CONCLUSIONS

POCUS exhibited high diagnostic accuracy for virtually all conditions when performed by emergency department physicians.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Ruptured abdominal aortic aneurysm discovered by pocket-sized ultrasound in a low resource setting: a case report

BACKGROUND

Abdominal aortic aneurysm (AAA) is a life-threatening condition characterized by the weakening and dilation of the abdominal aorta. AAA primarily affects men, smokers, and the elderly, with rupture being a fatal complication. While point-of-care ultrasound (POCUS) is valuable in diagnosing AAA, the role of using pocket-sized ultrasound in a low resource setting remains less explored. This case report presents a unique instance of a suspected ruptured AAA diagnosed using pocket-sized ultrasound in an emergency department (ED) situated in a low resource setting where ultrasound machines are absent, and emergency physicians lack proficiency in ultrasound usage.

CASE PRESENTATION

A 78-year-old man with a history of hypertension and bladder cancer presented to the ED with suprapubic pain. Initial evaluation showed no concerning findings. However, the next day, he collapsed, became unconscious, and experienced a cardiac arrest. Despite resuscitation efforts, the patient's condition deteriorated. POCUS revealed an 8-cm dilated abdominal aorta with an intimal flap, indicative of a dissecting AAA and a substrate for AAA rupture. Unfortunately, the patient died despite resuscitation efforts.

CONCLUSION

This case highlights the importance of considering AAA in patients with risk factors and abdominal pain in a low resource setting. POCUS using a pocket-sized ultrasound can aid in early AAA detection, potentially preventing rupture through preemptive vascular intervention. Emergency departments should prioritize ultrasound availability, and emergency physicians should be proficient in its use.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective

Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.

ACR Appropriateness Criteria® Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm: 2023 Update

Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41-91% and 94-100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50-100% and 93-100%, respectively; for >45 mm ranges were 64-65% and 95-99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.

A Case Report on the Diagnosis of Acute Abdominal Aortic Occlusion Using Point-of-Care Ultrasound in the Emergency Department

Point-of-care ultrasound (PoCUS) can be used to detect and evaluate for an aneurysm and/or a dissection of the abdominal aorta in suspected patients in the Emergency Department (ED). Despite the routine use of PoCUS for the assessment of the abdominal aorta in suspected aortic aneurysms and dissections, there is limited literature regarding its use in the diagnosis of acute abdominal aortic occlusions in the emergency setting. This is a case demonstrating the use of PoCUS in identifying an acute aortic occlusion in a 71-year-old female patient with known hypertension and diabetes mellitus. The patient presented with central abdominal pain and bilateral lower limb weakness to the ED. The patient had multiple differential diagnoses, including a possible acute aortic occlusion of the abdominal aorta. PoCUS of the aorta was utilized to diagnose an acute abdominal aortic occlusion in the ED. The rapid diagnosis expedited the referral to vascular surgeons for definitive management. Acute abdominal aortic occlusion is a time-sensitive and life-threatening emergency. PoCUS of the abdominal aorta to detect acute abdominal occlusions allows for a rapid diagnosis with the potential to improve outcomes. A protocol for detecting acute abdominal aortic occlusion should be included in the standard aorta PoCUS scan.

Emergency department point-of-care ultrasound diagnosis of active bleeding into the intraluminal thrombus of an abdominal aortic aneurysm

Rupture of an abdominal aortic aneurysm (AAA) is an immediately life-threatening phenomenon with substantial mortality. Although most AAAs are asymptomatic, an impending AAA rupture can be heralded by nonspecific symptoms and imaging findings on CT and point-of-care ultrasound (POCUS). In this report, we present a case of an 81-year-old male with an atypical presentation of an AAA with novel sonographic findings of imminent rupture on POCUS with Doppler that prompted successful emergent intervention. In the emergency department, imaging findings on aortic POCUS and CT imaging with angiography can facilitate assessment for impending aortic rupture, which can expedite appropriate disposition and potentially life-saving intervention.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

BACKGROUND

Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.

METHODS

MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31^st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.

RESULTS

Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.

CONCLUSIONS

The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting

Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.

Does Patient Weight, Age, or Gender Correlate With the Ability to Visualize the Distal Aorta on Bedside Aortic Ultrasounds in the Emergency Department?

INTRODUCTION

Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound.  Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans.  Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded.  Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019). Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization.

CONCLUSION

There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Point-of-care ultrasound for acute abdomen: 5W1H (Translated version)

In this paper, point-of-care ultrasound (POCUS) for the initial diagnosis and the management of acute abdomen is discussed. POCUS is supposed to be executed mainly by doctors other than ultrasound specialists anytime and anywhere such as in the emergency room or the intensive care unit. Although it seems rather difficult to cover the wide spectrum of organs as well as diseases causing acute abdominal pain, the author advocates a "six approach" for the diagnosis and triage of acute abdomen, which consists of scanning at eight points in less than 5 min. With this method, the attending doctor can diagnose most of the diseases frequently encountered in patients with acute abdomen, which can help patients avoid unnecessary examinations or admissions. However, users of POCUS should be aware of its limitations, especially when they are using pocket-sized ultrasound equipment. Therefore, users should be careful when ruling out a disease even when they cannot find any pathological findings, and consider the need for further examinations such as US done by specialists with high-end equipment or CT. Since there has been no standard curriculum in Japan for POCUS training that should deal with basic physics and techniques for US, normal abdominal anatomy, typical pathological US findings, and interventional US, the establishment of a learning program for doctors and training of experts as instructors of POCUS are needed.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Realistic and inexpensive ultrasound phantoms to demonstrate aortic aneurysm and aortic dissection

Introduction

Using ultrasound to evaluate for the presence of aortic pathology is a common procedure in the emergency department. Phantoms are models that are used to simulate clinical conditions for teaching ultrasound-related skills. To date, no 'homemade' phantom has been created to model aortic aneurysms, and no phantoms exist to model aortic dissection.

Methods

We used several readily available, inexpensive ingredients to create ultrasound phantoms.

Results

These phantoms realistically mimic aortic aneurysm and aortic dissection.

Discussion

These are the first 'homemade' phantoms that demonstrate aortic pathology.

Conclusions

We have created realistic, affordable, easily reproducible phantoms for use in teaching clinicians to use ultrasound when evaluating patients for aortic aneurysm and/or aortic dissection.

Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: Systematic review and meta-analysis

OBJECTIVES

Ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition, and rapid diagnosis is necessary to facilitate early surgical intervention. We sought to evaluate the accuracy of presenting symptoms, physical examination signs, computed tomography with angiography (CTA), and point-of-care ultrasound (PoCUS) for diagnosis of rAAA.

METHODS

We searched six databases from inception through April 2021. We included studies investigating the accuracy of any of the above tests for diagnosis of rAAA. The primary reference standard used in all studies was intraoperative diagnosis or death from rAAA. Because PoCUS cannot detect rupture, we secondarily assessed its accuracy for the diagnosis of AAA, using the reference standard of intraoperative or CTA diagnosis. We used GRADE to assess certainty in estimates.

RESULTS

We included 20 studies (2,077 patients), with 11 of these evaluating signs and symptoms, seven evaluating CTA, and five evaluating PoCUS. Pooled sensitivities of abdominal pain, back pain, and syncope for rAAA were 61.7%, 53.6%, and 27.8%, respectively (low certainty). Pooled sensitivity of hypotension and pulsatile abdominal mass were 30.9% and 47.1%, respectively (low certainty). CTA had a sensitivity of 91.4% and specificity of 93.6% for diagnosis of rAAA (moderate certainty). In our secondary analysis, PoCUS had a sensitivity of 97.8% and specificity of 97.0% for diagnosing AAA in patients suspected of having rAAA (moderate certainty).

CONCLUSIONS

Classic clinical symptoms associated with rAAA have poor sensitivity, and their absence does not rule out the condition. CTA has reasonable accuracy, but misses some cases of rAAA. PoCUS is a valuable tool that can help guide the need for urgent transfer to a vascular center in patients suspected of having rAAA.

Point-of-care Ultrasound for the Evaluation of Acute Arterial Pathology in the Emergency Department: A Case Series

Introduction

The use of point-of care ultrasound (POCUS) in the evaluation of vascular emergencies including abdominal aortic aneurysm and deep vein thrombosis is well established. However, no current guidelines exist to outline the use of POCUS in the management of acute peripheral arterial pathology.

Case Series

Here, we present a case series that illustrates the utility of POCUS in the assessment of both traumatic and nontraumatic peripheral arterial disease. Direct visualization of the vasculature via B-mode, color Doppler, and pulsed-wave Doppler assisted in the diagnosis of the following: 1) an acute, post-catheterization thrombus of the proximal radial artery; 2) a complete, traumatic radial artery transection; 3) a forearm hematoma with active arterial extravasation; 4) a traumatic arteriovenous fistula; 5) an acute thrombosis of an artery bypass graft; and 6) an infected pseudoaneurysm.

Conclusion

The incorporation of POCUS into patient care allowed for rapid identification of significant peripheral arterial pathology and led to changes in clinical management, expedited patient care, and circumvented potentially harmful complications.

Emergency Department Diagnosis of Multiple Mycotic Aneurysms in an HIV-Positive Patient Using Point-of-Care Ultrasound

We report the case of a transgender woman with HIV (CD4 349), shortness of breath, and chest pain, who was found to have multiple mycotic aortic aneurysms by point-of-care ultrasound (PoCUS). This report highlights the utility of point-of-care ultrasonography in the diagnosis and management of this rare clinical entity.Multiple mycotic aortic aneurysms and purulent pericarditis are uncommon. They have high morbidity and mortality and are associated with immunocompromised states (e.g., HIV). Diagnosis of the mycotic aneurysm, and its precursor, infectious aortitis, can be challenging, and delays in care can lead to poor outcomes. Often, as described in this case report, making the diagnosis requires a high clinical suspicion, multiple imaging modalities, and laboratory studies.

AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis

Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.

Rapid Bedside Ultrasound Evaluation of a Ruptured Abdominal Aortic Aneurysm With a Prior Repair

Ruptured aortic aneurysms carry a high risk of morbidity and mortality, particularly if not rapidly identified. We present an 87-year-old male, with a history of hypertension and prior endovascular aortic repair, who presented to the Emergency Department (ED) with several days of epigastric abdominal pain radiating to his back and flanks. The patient acutely deteriorated in the ED, and point-of-care ultrasound rapidly identified active extravasation from an abdominal aortic aneurysm with visualization of prior endograft. Point-of-care ultrasound in this patient expedited the diagnosis, resuscitation, and transfer to the operating room with definitive repair by vascular surgery. The patient recovered and was discharged in stable condition.

ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed

The initial diagnosis of retroperitoneal bleeding can be challenging by physical examination and clinical presentation. Prompt imaging can make the diagnosis and be lifesaving. When selecting appropriate imaging for these patient's, consideration must be made for sensitivity and ability to image the retroperitoneum, as well as speed of imaging.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Abdominal Pain in the Emergency Department: Missed Diagnoses

Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

OBJECTIVE

Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.

METHODS

Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.

RESULTS

A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462).

CONCLUSION

For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

Point-of-care ultrasound (POCUS) for hospitalists and general internists

Point-of-care ultrasound (POCUS) is currently implemented in various medical fields by clinicians for the bedside examination of patients. Evidence supports the fact that adding an ultrasound technology in daily practice (hand-held ultrasound device), called by some 'stethoscope of the future', improves patient care and allows an earlier diagnosis in a hospital setting. In this article, we reviewed the historical evolution of the use of ultrasound in medicine and the possibilities of using POCUS for hospitalists and general internists based on the existing scientific literature.

Disaster Diagnoses in Geriatric Patients with Abdominal Pain

Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. The incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients with an emphasis on high-risk presentations.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.

Screening for abdominal aortic aneurysm in patients with clinically manifest vascular disease

AIMS

Declining prevalence of abdominal aortic aneurysm (AAA) might force a more targeted screening approach (high-risk populations only) in order to maintain (cost-)effectiveness. We aimed to determine temporal changes in the prevalence of screening-detected AAA, to assess AAA-related surgery, and evaluate all-cause mortality in patients with manifest vascular disease.

METHODS AND RESULTS

We included patients with manifest vascular disease but without a history of AAA enrolled in the ongoing single-centre prospective UCC-SMART cohort study. Patients were screened at baseline for AAA by abdominal ultrasonography. We calculated sex- and age-specific prevalence of AAA, probability of survival in relation to the presence of AAA, and the proportion of patients undergoing AAA-related surgery. Prevalence of screening-detected AAA in 5440 screened men was 2.5% [95% confidence interval (CI) 2.1-2.9%] and in 1983 screened women 0.7% (95% CI 0.4-1.1%). Prevalence declined from 1997 until 2017 in men aged 70-79 years from 8.1% to 3.2% and in men aged 60-69 years from 5.7% to 1.0%. 36% of patients with screening-detected AAA received elective AAA-related surgery during follow-up (median time until surgery = 5.3 years, interquartile range 2.5-9.1). Patients with screening-detected AAA had a lower probability of survival (sex and age adjusted) compared to patients without screening-detected AAA (51%, 95% CI 41-64% vs. 69%, 95% CI 68-71%) after 15 years of follow-up.

CONCLUSION

The prevalence of screening-detected AAA has declined over the period 1997-2017 in men with vascular disease but exceeds prevalence in already established screening programs targeting 65-year-old men. Screening for AAA in patients with vascular disease may be cost-effective, but this remains to be determined.

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives

Background

Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results.

Methods

The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint.

Results

The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling better information sharing, implementing adequate planning and utilising technology were also identified in the practice interviews as viable strategies to improve test result communication. The citizen panel highlighted technology as critical to improving communication of test results to both health professionals and patients. Patients also highlighted the importance of having different ways of accessing test results, which is particularly pertinent when ensuring suitability for vulnerable populations.

Conclusions

This paper draws together multiple perspectives on the problem of failures in diagnostic test results communication to inform appropriate interventions. Across the three studies, technology was identified as the most feasible option for closing the loop on test result communication. However, the importance of clear, consistent communication and more streamlined processes were also key elements that emerged.

Review registration

The protocol for the rapid review was registered with PROSPERO CRD42018093316.

Application of Point-of-Care Ultrasound for Family Medicine Physicians for Abdominopelvic and Soft Tissue Assessment

Point-of-care ultrasound (POCUS) improves both the sensitivity and specificity with which clinicians can make a variety of diagnoses at the bedside from abdominal aortic aneurysm to kidney stones. In outpatient clinics, urgent care centers, and emergency departments, where ultrasound imaging may be delayed by hours or even days, the use of POCUS can be very helpful. We believe that POCUS facilitates both the triage of patients and provides diagnostic information quickly. We hope to advance the use of POCUS in the primary care setting and have reviewed six sonographic topics where we believe ultrasound can be of immense assistance to the physician in the outpatient setting.

A Case Report on Endovascular Aortic Repair Rupture

Endovascular repair of an abdominal aortic aneurysm (AAA) is a widely accepted alternative to open surgical AAA repair. A ruptured AAA is among the emergency surgeries with the highest risk of death, with an overall mortality rate close to90%. However, the classic symptom triad for ruptured AAAs of hypotension, a pulsatile mass, and abdominal/back pain is seen in only in 25% to 50% of affected patients. Thus, many present with symptoms and signs that suggest adifferent diagnosis. Recognizing uncommon presentations and limitations of imaging and interpretation, in addition to clinical gestalt, can save many lives. This report discusses an unusual case involving a previously repaired AAA presenting with acute rupture at the endograft site.

Ruptured abdominal aortic aneurysm identified on point-of-care ultrasound in the emergency department

Background

Ruptured abdominal aortic aneurysm (AAA) is a highly lethal condition which requires rapid identification and treatment to improve the chance of survival. Computed tomography is the diagnostic modality of choice for ruptured AAA though it is time-consuming and often requires movement of the patient out of the emergency department (ED). Point-of-care ultrasound in the ED has excellent sensitivity and specificity for the detection of AAA, though less is known about its use to diagnose AAA rupture. We report a case of ruptured AAA identified on ultrasound performed at the bedside in the ED.

Case presentation

A 77-year-old woman on warfarin with a known AAA presented to our ED with 2 days of epigastric abdominal pain. Point-of-care ultrasound revealed several findings suggestive of rupture of the AAA, which was confirmed on computed tomography. The patient was subsequently taken for emergent operative repair of the AAA and was later discharged from the hospital.

Conclusions

Characteristics suggestive of AAA rupture may be seen on ultrasound. As ED physicians become more familiar with the use of point-of-care ultrasound in the evaluation of abdominal pain, identification of these characteristics may aid in the rapid diagnosis of AAA rupture.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Basic point-of-care ultrasound framework based on the airway, breathing, and circulation approach for the initial management of shock and dyspnea

Ultrasound (US) carried out and interpreted by clinicians at the bedside is now called point‐of‐care US (POCUS). Clinical studies on POCUS have been carried out based on the ideas of “creation”, “extraction”, and “combination”. “Creation” refers to findings for the upper airway and lung being obtained at the bedside. “Extraction” refers to findings suitable for POCUS being extracted from comprehensive US, including echocardiography, abdominal US, and whole‐leg US. “Combination” refers to these POCUS applications being combined for the comprehensive assessment of patients with trauma, shock, or dyspnea. Emergency and critical care physicians have many opportunities to encounter trauma or non‐trauma patients with shock, dyspnea, or both. Furthermore, the scope of POCUS includes many diseases and injuries that present with both shock and dyspnea. Therefore, we propose a basic POCUS framework based on the systematic airway, breathing, and circulation approach for the initial management of shock and dyspnea in adult patients. In this article, we update and review each application of POCUS and their combination in this framework. Furthermore, we propose the practical usage of the framework based on clinical presentations to improve the management of shock and dyspnea.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.