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Russell FM, Supples M, Tamhankar O, Liao M, Finnegan P. Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment. Acad Emerg Med 2024; 31:42-48. [PMID: 37772384 DOI: 10.1111/acem.14811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/30/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE Patients with acute heart failure (AHF) are commonly misdiagnosed and undertreated in the prehospital setting. These delays in diagnosis and treatment have a direct negative impact on patient outcomes. The goal of this study was to determine the diagnostic accuracy of paramedics with and without the use of lung ultrasound (LUS) for the diagnosis of AHF in patients with dyspnea in the prehospital setting. Secondarily, we assessed LUS impact on rate of and time to initiation of HF therapies. METHODS This was a prospective interventional study on a consecutive sample of patients transported to the hospital by one emergency medical services agency. Adult patients (>18 years) with a chief complaint of dyspnea were included. LUS was performed by trained paramedics and was defined as positive for AHF if both anterior-superior lung zones had greater than or equal to three B-lines or bilateral B-lines were visualized on a four-view protocol. Paramedic diagnosis was compared to hospital discharge diagnosis which served as the criterion standard. RESULTS Of the 264 included patients, 94 (35%) had a final diagnosis of AHF. Forty total patients had a LUS performed; 17 of these patients had a final diagnosis of AHF. Sensitivity and specificity for AHF by paramedics were 23% (95% confidence interval [CI] 0.14-0.34) and 97% (95% CI 0.92-0.99) without LUS and 71% (95% CI 0.44-0.88) and 96% (95% CI 0.76-0.99) with the use of LUS. In the 94 patients with AHF, 14% (11/77) received HF therapy prehospital without the use of LUS and 53% (9/17) with the use of LUS. LUS improved frequency of treatment by 39%. Median time to treatment was 21 min with LUS and 169 min without. CONCLUSIONS LUS improved paramedic sensitivity and accuracy for diagnosing AHF in the prehospital setting. LUS use led to higher rates of prehospital HF therapy initiation and significantly decreased time to treatment.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Omkar Tamhankar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Liao
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patrick Finnegan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Gargani L, Girerd N, Platz E, Pellicori P, Stankovic I, Palazzuoli A, Pivetta E, Miglioranza MH, Soliman-Aboumarie H, Agricola E, Volpicelli G, Price S, Donal E, Cosyns B, Neskovic AN. Lung ultrasound in acute and chronic heart failure: a clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Imaging 2023; 24:1569-1582. [PMID: 37450604 PMCID: PMC11032195 DOI: 10.1093/ehjci/jead169] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, via Paradisa 2 5614, Pisa, Italy
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, CHRU de Nancy, INSERM DCAC, F-CRIN INI-CRCT, Nancy, France
| | - Elke Platz
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ivan Stankovic
- Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Italy
| | - Emanuele Pivetta
- Medicina d'Urgenza-MECAU, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Hatem Soliman-Aboumarie
- Department of Cardiothoracic Anaesthesia and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, King’s College London, UK
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino, Italy
| | - Susanna Price
- Departments of Cardiology & Intensive Care, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, Rennes, France
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Jette, Brussels, Belgium
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Gupta PB, Lighthall G, Htet N. Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units. Cureus 2023; 15:e49114. [PMID: 38125228 PMCID: PMC10732337 DOI: 10.7759/cureus.49114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.
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Affiliation(s)
- Pranjal B Gupta
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
| | - Geoffrey Lighthall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, USA
- Department of Anesthesia, Veterans Affairs Medical Center, Palo Alto, USA
| | - Natalie Htet
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
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4
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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Huang CT, Chang CH, Chen JY, Ling DA, Lee AF, Wang PH, Wu CK, Ko YC, Hsiao YT, Lien WC, Chang WT, Huang CH. The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:389-394. [PMID: 37072032 DOI: 10.1055/a-2048-6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.
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Affiliation(s)
- Chien-Tai Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Heng Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Yu Chen
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Dean-An Ling
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - An-Fu Lee
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Hsiu Wang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Kai Wu
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chih Ko
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tse Hsiao
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ching Lien
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Tien Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
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Reinoso Párraga PP, Vilches-Moraga A. Is point of care ultrasound (POCUS) useful for the evaluation of blood volume and alveolar-interstitial syndrome in older patients? Series of cases. Rev Esp Geriatr Gerontol 2023; 58:167-169. [PMID: 37080823 DOI: 10.1016/j.regg.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
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7
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Núñez-Ramos JA, Aguirre-Acevedo DC, Pana-Toloza MC. Point of care ultrasound impact in acute heart failure hospitalization: A retrospective cohort study. Am J Emerg Med 2023; 66:141-145. [PMID: 36753930 DOI: 10.1016/j.ajem.2023.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/26/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) is one of the most frequent causes of emergency department (ED) visits. Point-of-Care Ultrasound (POCUS) is a reliable, easy-to-use, and available tool for an accurate diagnosis of ADHF. We aimed to analyze the impact of introducing POCUS as an additional tool to clinical standard diagnosis in clinical times of hospitalized heart failure patients. METHODS Retrospective cohort study comparing patients consulting to ED for heart failure acute decompensation previous to the rutinary use of POCUS versus patients who received an ultrasound-guided diagnosis at entrance. Ultrasound evaluation was additional to standard diagnosis (which included natriuretic peptides, images, etc). Cumulative incidence functions were calculated for time to treatment, time to disposition decision, and time to discharge. We used a flexible parametric model for estimate the time ratio (TR) in order to reflect the effect of POCUS. RESULTS A total of 149 patients were included. The most frequent comorbid condition was hypertension (71.8%) followed by type 2 diabetes (36.2%). B type natriuretic peptide (BNP) was over 500 ng/ml. Most patients had Stevenson B profile (83.9%) at admission. In the cumulative incidence model (Fig. A), the TR (time ratio) for the outcome time to treatment was 1.539 (CI 95% 0.88 to 2.69). The TR for the outcome time to disposition decision was 0.665 (CI 95% 0.48 to 0.99). The TR for the outcome time to discharge (hospital length of stay) was 0.663 (CI 95% 0.49 to 0.90). CONCLUSION In our study, the introduction of POCUS to ADHF patients decreases time to disposition decision and total length of hospital stay. Conversely, time to treatment augments. There is need for the evaluation of ultrasound as an intervention in clinical trials to confirm these findings.
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Affiliation(s)
- José Atilio Núñez-Ramos
- Hospital Universidad del Norte, Emergency Department, Colombia; Universidad del Norte, Health Science Division, Colombia.
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Szabó GV, Szigetváry C, Szabó L, Dembrovszky F, Rottler M, Ocskay K, Madzsar S, Hegyi P, Molnár Z. Point-of-care ultrasound improves clinical outcomes in patients with acute onset dyspnea: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:639-653. [PMID: 36310302 PMCID: PMC10017566 DOI: 10.1007/s11739-022-03126-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
The early, appropriate management of acute onset dyspnea is important but often challenging. The aim of this study was to investigate the effects of the use of Point-of-Care Ultrasound (PoCUS) versus conventional management on clinical outcomes in patients with acute onset dyspnea. The Cochrane Library, MEDLINE, EMBASE and reference lists were searched to identify eligible trials (inception to October 14, 2021). There were no language restrictions. Randomized controlled trials (RCTs), and prospective and retrospective cohort studies that compared PoCUS with conventional diagnostic modalities (controls) in patients with acute onset dyspnea were included. Two independent reviewers extracted data and assessed the risk of bias. Disagreements were resolved by consensus. The primary study outcomes were time to diagnosis, time to treatment, and length of stay (LOS). Secondary outcomes included rate of appropriate treatment, 30-day re-admission rate, and mortality. We included eight RCTs and six observational studies with a total of 5393 participants. Heterogeneity across studies was variable (from low to considerable), with overall low or moderate study quality and low or moderate risk of bias (except one article with serious risk of bias). Time to diagnosis (mean difference [MD], - 63 min; 95% CI, - 115 to - 11 min] and time to treatment (MD, - 27 min; 95% CI - 43 to - 11 min) were significantly shorter in the PoCUS group. In-hospital LOS showed no differences between the two groups, but LOS in the Intensive Care Unit (MD, - 1.27 days; - 1.94 to - 0.61 days) was significantly shorter in the PoCUS group. Patients in the PoCUS group showed significantly higher odds of receiving appropriate therapy compared to controls (odds ratio [OR], 2.31; 95% CI, 1.61-3.32), but there was no significant effect on 30-day re-admission rate and in-hospital or 30-day mortality. Our results indicate that PoCUS use contributes to early diagnosis and better outcomes compared to conventional methods in patients admitted with acute onset dyspnea.
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Affiliation(s)
- Gergő Vilmos Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Emergency Department, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
- National Ambulance Service, Budapest, Hungary
- Hungarian Air Ambulance Nonprofit Ltd., Budaörs, Hungary
| | - Csenge Szigetváry
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Fanni Dembrovszky
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Máté Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Department of Anesthesiology and Intensive Therapy, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Klemetina Ocskay
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Stefanie Madzsar
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Poznan University, Poznan, Poland.
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Gutowski JN, Donovan DJ, Firnberg MT, Constantinescu A, Kennedy TM. A Rare Complication of Anomalous Left Coronary Artery From the Pulmonary Artery Identified by Point-of-Care Ultrasound. Pediatr Emerg Care 2023; 39:201-203. [PMID: 36173337 DOI: 10.1097/pec.0000000000002851] [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: 11/27/2022]
Abstract
ABSTRACT Point-of-care ultrasound is a valuable tool in the evaluation of undifferentiated respiratory distress in children. This case report describes a 9-month-old male infant who presented with 4 months of progressively worsening cough and was found to be tachypneic in the emergency department. Chest radiography revealed complete opacification of the left hemithorax with cardiomegaly. Point-of-care ultrasound demonstrated atelectasis of the entire left lung and severe dilation of the left ventricle with poor function. Electrocardiogram and echocardiogram findings were consistent with a diagnosis of anomalous left coronary artery from the pulmonary artery. The patient underwent successful cardiac surgery to improve myocardial perfusion. Bronchoscopy visualized the etiology of his atelectasis, pulsatile compression of the left mainstem bronchus by the dilated heart. Focused cardiac and lung ultrasound techniques, as well as pertinent sonographic findings, are reviewed.
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Affiliation(s)
| | | | - Maytal T Firnberg
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine
| | - Andrei Constantinescu
- Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Thomas M Kennedy
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine
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10
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Accuracy of Critical Care Ultrasonography Plus Arterial Blood Gas Analysis Based Algorithm in Diagnosing Aetiology of Acute Respiratory Failure. J Crit Care Med (Targu Mures) 2023; 9:20-29. [PMID: 36890971 PMCID: PMC9987272 DOI: 10.2478/jccm-2023-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Lung ultrasound when used in isolation, usually misses out metabolic causes of dyspnoea and differentiating acute exacerbation of COPD from pneumonia and pulmonary embolism is difficult, hence we thought of combining critical care ultrasonography (CCUS) with arterial blood gas analysis (ABG). Aim of the study The objective of this study was to estimate accuracy of Critical Care Ultrasonography (CCUS) plus Arterial blood gas (ABG) based algorithm in diagnosing aetiology of dyspnoea. Accuracy of traditional Chest X-ray (CxR) based algorithm was also validated in the following setting. Methods It was a facility based comparative study, where 174 dyspneic patients were subjected to CCUS plus ABG and CxR based algorithms on admission to ICU. The patients were classified into one of five pathophysiological diagnosis 1) Alveolar( Lung-pneumonia)disorder ; 2) Alveolar (Cardiac-pulmonary edema) disorder; 3) Ventilation with Alveolar defect (COPD) disorder ;4) Perfusion disorder; and 5) Metabolic disorder. We calculated diagnostic test properties of CCUS plus ABG and CXR based algorithm in relation to composite diagnosis and correlated these algorithms for each of the defined pathophysiological diagnosis. Results The sensitivity of CCUS and ABG based algorithm was 0.85 (95% CI-75.03-92.03) for alveolar (lung) ; 0.94 (95% CI-85.15-98.13) for alveolar (cardiac); 0.83 (95% CI-60.78-94.16) for ventilation with alveolar defect; 0.66 (95% CI-30-90.32) for perfusion defect; 0.63 (95% CI-45.25-77.07) for metabolic disorders.Cohn's kappa correlation coefficient of CCUS plus ABG based algorithm in relation to composite diagnosis was 0.7 for alveolar (lung), 0.85 for alveolar (cardiac), 0.78 for ventilation with alveolar defect, 0.79 for perfusion defect and 0.69 for metabolic disorders. Conclusion CCUS plus ABG algorithm is highly sensitive and it's agreement with composite diagnosis is far superior. It is a first of it's kind study, where authors have attempted combining two point of care tests and creating an algorithmic approach for timely diagnosis and intervention.
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Kok B, Wolthuis D, Bosch F, van der Hoeven H, Blans M. POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence. Eur J Intern Med 2022; 106:9-38. [PMID: 35927185 DOI: 10.1016/j.ejim.2022.07.017] [Citation(s) in RCA: 2] [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: 05/02/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration. METHODS Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test. CONCLUSION We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment. TRIAL REGISTRY INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/.
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Affiliation(s)
- Bram Kok
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands.
| | - David Wolthuis
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands
| | - Frank Bosch
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands; Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands
| | | | - Michiel Blans
- Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands; Intensive Care Unit, Rijnstate, Arnhem, the Netherlands
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Winters M, Ezema B, Ogedegbe C, Stoupakis G. A Pressing Matter: Compressive Postoperative Hematoma Causing Acute Diastolic Heart Failure. J Emerg Med 2022; 63:781-786. [PMID: 36369117 DOI: 10.1016/j.jemermed.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/11/2022] [Accepted: 09/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiopulmonary complications in the postoperative period can lead to significant morbidity and mortality. Many of the complications in the postoperative period occur after discharge from the hospital, and up to 25% of patients will require readmission. In postoperative patients presenting to the emergency department (ED), it is important to consider that postoperative complications can affect a multitude of organ systems, including those that are adjacent to where the surgery was performed. CASE REPORT We present the case of a 54-year-old woman presenting to the ED with shortness of breath in the setting of recent Nissen fundoplication revision. Pulmonary angiography was significant for a large hiatal hernia and negative for pulmonary embolism. She was discharged and returned to the ED a few days later due to worsening symptoms. Further diagnostic studies demonstrated an esophageal hematoma causing compression of the left atrium, leading to acute diastolic heart failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to consider alternative etiologies for common complaints in the postoperative patient presenting to the ED. Early involvement of the operative team in the patient's care can assist in directing diagnostic approach and management of the postoperative patient.
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Affiliation(s)
- Megan Winters
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, New Jersey
| | - Bryan Ezema
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Chinwe Ogedegbe
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, New Jersey
| | - George Stoupakis
- Department of Cardiology, Hackensack University Medical Center, Hackensack, New Jersey
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Russell FM, Herbert A, Peterson D, Wallach PM, Ferre RM. Assessment of Medical Students' Ability to Integrate Point-of-Care Cardiac Ultrasound Into a Case-Based Simulation After a Short Intervention. Cureus 2022; 14:e27513. [PMID: 36060409 PMCID: PMC9424786 DOI: 10.7759/cureus.27513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/05/2022] Open
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14
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Baid H, Vempalli N, Kumar S, Arora P, Walia R, Chauhan U, Shukla K, Verma A, Chawang H, Agarwal D. Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study. Int J Emerg Med 2022; 15:27. [PMID: 35698060 PMCID: PMC9190130 DOI: 10.1186/s12245-022-00430-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings. Methodology The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared. Results Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5–264) min compared to the 170 (8–1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001). Conclusion By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients’ prompt management and disposition with reliable accuracy. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-022-00430-8.
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Affiliation(s)
- Himanshi Baid
- Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Nagasubramanyam Vempalli
- Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India.
| | - Subodh Kumar
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Gorakhpur, Gorakhpur, Uttar Pradesh, 273008, India
| | - Poonam Arora
- Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Rohit Walia
- Department of Cardiology, All India Institute of Medical Sciences Bhatinda, Rishikesh, Punjab, 151001, India
| | - Udit Chauhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Krishna Shukla
- Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Aakash Verma
- Department of Emergency Medicine, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, 302022, India
| | - Hannah Chawang
- Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Disha Agarwal
- All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, 249203, India
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15
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Spiliotaki E, Saranteas T, Moschovaki N, Panagouli K, Pistioli E, Kitsinelis V, Briasoulis P, Papadimos T. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: A critical analysis review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:733-744. [PMID: 35302241 DOI: 10.1002/jcu.23194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
Rapid evaluation of intravascular volume status is vital; either excessive or limited fluid administration may result in adverse patient outcomes. In this narrative review, critical analysis of pertinent diagnostic accuracy studies is developed to delineate the role of inferior vena cava ultrasound measurements in the assessment of both intravascular volume status and fluid responsiveness in the emergency department and intensive care unit. In addition, limitations, and technical considerations of inferior vena cava ultrasound measurements as well as directions for future research are thoroughly discussed.
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Affiliation(s)
- Eleni Spiliotaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nefeli Moschovaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Panagouli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathia Pistioli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Kitsinelis
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Briasoulis
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Papadimos
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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16
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The Parasternal Long Axis View in Isolation: Is it Good Enough? J Emerg Med 2022; 62:769-774. [PMID: 35562250 DOI: 10.1016/j.jemermed.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/31/2022] [Accepted: 02/25/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination. OBJECTIVE Our primary goal was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction, and right ventricular (RV) dilatation compared with a four-view FOCUS examination. METHODS This was a retrospective study looking at FOCUS images. Examinations were blinded and randomized for review by point-of-care ultrasound faculty. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation with findings on a full four-view FOCUS examination, which served as the criterion standard. Sensitivity and specificity were calculated. RESULTS Of 100 FOCUS examinations; 36% were normal, 16% had a pericardial effusion, 41% had an LV ejection fraction < 50%, and 7% had RV dilatation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction, and RV dilatation were 81% (confidence interval [CI] 0.54-0.95) and 98% (95% CI 0.91-0.99), 100% (95% CI 0.88-1) and 91% (95% CI 0.80-0.97), and 71% (95% CI 0.30-0.94) and 99% (95% CI 0.93-1), respectively. All moderate to large effusions were identified correctly. Overall, there were only four clinically significant disagreements between PSLA alone and the four-view interpretations. CONCLUSIONS In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.
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17
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Usefulness of Multi-Organ Point-of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine. J Clin Med 2022; 11:jcm11082256. [PMID: 35456356 PMCID: PMC9032971 DOI: 10.3390/jcm11082256] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/16/2022] [Accepted: 04/17/2022] [Indexed: 02/04/2023] Open
Abstract
Accumulated data show the utility of diagnostic multi-organ point-of-care ultrasound (PoCUS) in the assessment of patients admitted to an internal medicine ward. We assessed whether multi-organ PoCUS (lung, cardiac, and abdomen) provides relevant diagnostic and/or therapeutic information in patients admitted for any reason to an internal medicine ward. We conducted a prospective, observational, and single-center study, at a secondary hospital. Multi-organ PoCUS was performed during the first 24 h of admission. The sonographer had access to the patients’ medical history, physical examination, and basic complementary tests performed in the Emergency Department (laboratory, X-ray, electrocardiogram). We considered a relevant ultrasound finding if it implied a significant diagnostic and/or therapeutic change. In the second semester of 2019, we enrolled 310 patients, 48.7% were male and the mean age was 70.5 years. Relevant ultrasound findings were detected in 86 patients (27.7%) and in 60 (19.3%) triggered a therapeutic change. These findings were associated with an older age (Mantel−Haenszel χ2 = 25.6; p < 0.001) and higher degree of dependency (Mantel−Haenszel χ2 = 5.7; p = 0.017). Multi-organ PoCUS provides relevant diagnostic information, complementing traditional physical examination, and facilitates therapy adjustment, regardless of the cause of admission. Multi-organ PoCUS to be useful need to be systematically integrated into the decision-making process in internal medicine.
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18
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Kennedy SK, Ferre RM, Rood LK, Nti B, Ehrman RR, Brenner D, Rutz MA, Zahn GS, Herbert AG, Russell FM. Success of implementation of a systemwide point-of-care ultrasound privileging program for emergency medicine faculty. AEM EDUCATION AND TRAINING 2022; 6:e10744. [PMID: 35493291 PMCID: PMC9045579 DOI: 10.1002/aet2.10744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians received POCUS training during residency, leaving a training gap that is reflected in POCUS privileging. The purpose of this study was to evaluate the success of meeting privileging criteria as well as associated factors, following implementation of a basic POCUS training and privileging program within a large emergency medicine department. METHODS We implemented a POCUS training and privileging program, based on national guidelines, for faculty physicians who worked at one of the following EDs staffed by the same emergency medicine department: a pediatric tertiary site, two tertiary academic sites, and seven community sites. POCUS examinations included aorta, cardiac, first-trimester obstetrics (OB), and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic US instead of aorta and OB. Completion of the program required 16 h of didactics, ≥25 quality-assured US examinations by examination type, and passing a series of knowledge-based examinations. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth's logistic regression. RESULTS A total of 176 faculty physicians were eligible. A total of 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including 86 (48.9%) practice-based, nine (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (odds ratio 0.3, 95% confidence interval 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success. CONCLUSIONS Implementation of a POCUS training and privileging program can be successful in a large emergency medicine department that staffs hospitals in a large-scale health care system composed of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful.
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Affiliation(s)
- Sarah K. Kennedy
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Robinson M. Ferre
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Loren K. Rood
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Benjamin Nti
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Robert R. Ehrman
- Department of Emergency MedicineWayne State University School of MedicineDetroit Medical Center/Sinai‐Grace HospitalDetroitMichiganUSA
| | - Daniel Brenner
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Matt A. Rutz
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Greg S. Zahn
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Audrey G. Herbert
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Frances M. Russell
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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19
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Russell FM, Kennedy SK, Rood LK, Nti B, Herbert A, Rutz MA, Palmer M, Ferre RM. Design and implementation of a basic and global point of care ultrasound (POCUS) certification curriculum for emergency medicine faculty. Ultrasound J 2022; 14:10. [PMID: 35182232 PMCID: PMC8858359 DOI: 10.1186/s13089-022-00260-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
Point of care ultrasound (POCUS) use in the emergency department is associated with improved patient outcomes and increased patient satisfaction. When used for procedural guidance, it has been shown to increase first pass success and decrease complications. As of 2012, ultrasound has been identified as a core skill required for graduating emergency medicine (EM) residents. Despite this, only a minority of EM faculty who trained prior to 2008 are credentialed in POCUS. Half of all EM training programs in the United States have less than 50% of their faculty credentialed to perform and teach POCUS to learners. As the use of POCUS continues to grow in medicine, it is especially important to have a pathway for faculty to attain competence and become credentialed in POCUS. The goal of this paper was to outline an implementation process of a curriculum designed to credential EM faculty in POCUS.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA.
| | - Sarah K Kennedy
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Loren K Rood
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Benjamin Nti
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Audrey Herbert
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Matt A Rutz
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Megan Palmer
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Robinson M Ferre
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
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20
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Albaroudi B, Haddad M, Albaroudi O, Abdel-Rahman ME, Jarman R, Harris T. Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis. Eur J Emerg Med 2022; 29:18-32. [PMID: 34406134 PMCID: PMC8691376 DOI: 10.1097/mej.0000000000000866] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/28/2021] [Indexed: 01/23/2023]
Abstract
Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.
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Affiliation(s)
| | - Mahmoud Haddad
- Department of Emergency Medicine, Hamad Medical Corporation
| | - Omar Albaroudi
- Department of Emergency Medicine, Hamad Medical Corporation
| | | | - Robert Jarman
- Emergency Department, Royal Victoria Infirmary, Newcastle upon Tyne
- Teesside University, Middlesbrough
| | - Tim Harris
- Department of Emergency Medicine, Hamad Medical Corporation
- Barts Health NHS Trust and the Queen Mary University of London, London, UK
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21
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Heldeweg MLA, Vermue L, Kant M, Brouwer M, Girbes ARJ, Haaksma ME, Heunks LMA, Mousa A, Smit JM, Smits TW, Paulus F, Ket JCF, Schultz MJ, Tuinman PR. The impact of lung ultrasound on clinical-decision making across departments: a systematic review. Ultrasound J 2022; 14:5. [PMID: 35006383 PMCID: PMC8748548 DOI: 10.1186/s13089-021-00253-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background Lung ultrasound has established itself as an accurate diagnostic tool in different clinical settings. However, its effects on clinical-decision making are insufficiently described. This systematic review aims to investigate the impact of lung ultrasound, exclusively or as part of an integrated thoracic ultrasound examination, on clinical-decision making in different departments, especially the emergency department (ED), intensive care unit (ICU), and general ward (GW). Methods This systematic review was registered at PROSPERO (CRD42021242977). PubMed, EMBASE, and Web of Science were searched for original studies reporting changes in clinical-decision making (e.g. diagnosis, management, or therapy) after using lung ultrasound. Inclusion criteria were a recorded change of management (in percentage of cases) and with a clinical presentation to the ED, ICU, or GW. Studies were excluded if examinations were beyond the scope of thoracic ultrasound or to guide procedures. Mean changes with range (%) in clinical-decision making were reported. Methodological data on lung ultrasound were also collected. Study quality was scored using the Newcastle–Ottawa scale. Results A total of 13 studies were included: five studies on the ED (546 patients), five studies on the ICU (504 patients), two studies on the GW (1150 patients), and one study across all three wards (41 patients). Lung ultrasound changed the diagnosis in mean 33% (15–44%) and 44% (34–58%) of patients in the ED and ICU, respectively. Lung ultrasound changed the management in mean 48% (20–80%), 42% (30–68%) and 48% (48–48%) of patients in the ED, in the ICU and in the GW, respectively. Changes in management were non-invasive in 92% and 51% of patients in the ED and ICU, respectively. Lung ultrasound methodology was heterogeneous across studies. Risk of bias was moderate to high in all studies. Conclusions Lung ultrasound, exclusively or as a part of thoracic ultrasound, has substantial impact on clinical-decision making by changing diagnosis and management in the EDs, ICUs, and GWs. The current evidence level and methodological heterogeneity underline the necessity for well-designed trials and standardization of methodology. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-021-00253-3.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands. .,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.
| | - Lian Vermue
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Max Kant
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Michelle Brouwer
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
| | - Thomas W Smits
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Johannes C F Ket
- Medical Library, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
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22
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Cid-Serra X, Royse A, Canty D, Johnson DF, Maier AB, Fazio T, El-Ansary D, Royse CF. Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2138228. [PMID: 34932107 PMCID: PMC8693211 DOI: 10.1001/jamanetworkopen.2021.38228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. OBJECTIVE To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. DESIGN, SETTING, AND PARTICIPANTS This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. INTERVENTIONS The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. MAIN OUTCOMES AND MEASURES The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. RESULTS A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.
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Affiliation(s)
- Ximena Cid-Serra
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alistair Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Canty
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Anesthesia and Perioperative Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Douglas F. Johnson
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of General Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrea B. Maier
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universitet, Amsterdam, The Netherlands
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Fazio
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Health Intelligence Unit, Melbourne Health, Melbourne, Victoria, Australia
- Department of Medicine and Radiology, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Doa El-Ansary
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Melbourne, Victoria, Australia
- Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Research Institute, Westmead Private Hospital, Westmead, Sydney, New South Wales, Australia
| | - Colin F. Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio
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Gartlehner G, Wagner G, Affengruber L, Chapman A, Dobrescu A, Klerings I, Kaminski-Hartenthaler A, Spiel AO. Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med 2021; 174:967-976. [PMID: 33900798 DOI: 10.7326/m20-5504] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up. PURPOSE To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419). DATA SOURCES Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews. STUDY SELECTION Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion. DATA EXTRACTION Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence. DATA SYNTHESIS Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies. LIMITATIONS Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results. CONCLUSION Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea. PRIMARY FUNDING SOURCE American College of Physicians.
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Affiliation(s)
- Gerald Gartlehner
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria, and RTI International, Research Triangle Park, North Carolina (G.G.)
| | - Gernot Wagner
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria (G.W., L.A., A.C., A.D., I.K., A.K.)
| | - Lisa Affengruber
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria (G.W., L.A., A.C., A.D., I.K., A.K.)
| | - Andrea Chapman
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria (G.W., L.A., A.C., A.D., I.K., A.K.)
| | - Andreea Dobrescu
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria (G.W., L.A., A.C., A.D., I.K., A.K.)
| | - Irma Klerings
- Cochrane Austria, Danube University Krems, Krems an der Donau, Austria (G.W., L.A., A.C., A.D., I.K., A.K.)
| | | | - Alexander O Spiel
- Medical University of Vienna and Wilhelminen Hospital, Vienna, Austria (A.O.S.)
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24
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House DR, Amatya Y, Nti B, Russell FM. Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting. Ultrasound J 2021; 13:34. [PMID: 34191145 PMCID: PMC8245620 DOI: 10.1186/s13089-021-00236-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Lung ultrasound (LUS) is helpful for the evaluation of patients with dyspnea in the emergency department (ED). However, it remains unclear how much training and how many LUS examinations are needed for ED physicians to obtain proficiency. The objective of this study was to determine the threshold number of LUS physicians need to perform to achieve proficiency for interpreting LUS on ED patients with dyspnea. Methods A prospective study was performed at Patan Hospital in Nepal, evaluating proficiency of physicians novice to LUS. After eight hours of didactics and hands-on training, physicians independently performed and interpreted ultrasounds on patients presenting to the ED with dyspnea. An expert sonographer blinded to patient data and LUS interpretation reviewed images and provided an expert interpretation. Interobserver agreement was performed between the study physician and expert physician interpretation. Cumulative sum analysis was used to determine the number of scans required to attain an acceptable level of training. Results Nineteen physicians were included in the study, submitting 330 LUS examinations with 3288 lung zones. Eighteen physicians (95%) reached proficiency. Physicians reached proficiency for interpreting LUS accurately when compared to an expert after 4.4 (SD 2.2) LUS studies for individual zone interpretation and 4.8 (SD 2.3) studies for overall interpretation, respectively. Conclusions Following 1 day of training, the majority of physicians novice to LUS achieved proficiency with interpretation of lung ultrasound after less than five ultrasound examinations performed independently.
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Affiliation(s)
- Darlene R House
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal. .,Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
| | - Yogendra Amatya
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Benjamin Nti
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
| | - Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
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Russell FM, Ehrman RR, Barton A, Sarmiento E, Ottenhoff JE, Nti BK. B-line quantification: comparing learners novice to lung ultrasound assisted by machine artificial intelligence technology to expert review. Ultrasound J 2021; 13:33. [PMID: 34191132 PMCID: PMC8245599 DOI: 10.1186/s13089-021-00234-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of this study was to assess the ability of machine artificial intelligence (AI) to quantitatively assess lung ultrasound (LUS) B-line presence using images obtained by learners novice to LUS in patients with acute heart failure (AHF), compared to expert interpretation. METHODS This was a prospective, multicenter observational study conducted at two urban academic institutions. Learners novice to LUS completed a 30-min training session on lung image acquisition which included lecture and hands-on patient scanning. Learners independently acquired images on patients with suspected AHF. Automatic B-line quantification was obtained offline after completion of the study. Machine AI counted the maximum number of B-lines visualized during a clip. The criterion standard for B-line counts was semi-quantitative analysis by a blinded point-of-care LUS expert reviewer. Image quality was blindly determined by an expert reviewer. A second expert reviewer blindly determined B-line counts and image quality. Intraclass correlation was used to determine agreement between machine AI and expert, and expert to expert. RESULTS Fifty-one novice learners completed 87 scans on 29 patients. We analyzed data from 611 lung zones. The overall intraclass correlation for agreement between novice learner images post-processed with AI technology and expert review was 0.56 (confidence interval [CI] 0.51-0.62), and 0.82 (CI 0.73-0.91) between experts. Median image quality was 4 (on a 5-point scale), and correlation between experts for quality assessment was 0.65 (CI 0.48-0.82). CONCLUSION After a short training session, novice learners were able to obtain high-quality images. When the AI deep learning algorithm was applied to those images, it quantified B-lines with moderate-to-fair correlation as compared to semi-quantitative analysis by expert review. This data shows promise, but further development is needed before widespread clinical use.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, FOB 3rd Floor, Indianapolis, IN, 46202, USA.
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, 4021 St Antoine Ave, Suite 6G, Detroit, MI, 48201, USA
| | - Allen Barton
- Boone County Emergency Physicians, Zionsville, IN, 46077, USA
| | - Elisa Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, FOB 3rd Floor, Indianapolis, IN, 46202, USA
| | - Jakob E Ottenhoff
- Department of Emergency Medicine, Wayne State University School of Medicine, 4021 St Antoine Ave, Suite 6G, Detroit, MI, 48201, USA
| | - Benjamin K Nti
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, FOB 3rd Floor, Indianapolis, IN, 46202, USA
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26
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Miger KC, Fabricius-Bjerre A, Maschmann CP, Wamberg J, Winkler Wille MM, Abild-Nielsen AG, Pedersen L, Lawaetz Schultz HH, Damm Nybing J, Nielsen OW. Clinical Applicability of Lung Ultrasound Methods in the Emergency Department to Detect Pulmonary Congestion on Computed Tomography. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:e21-e30. [PMID: 31648347 DOI: 10.1055/a-1021-1470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND B-lines on lung ultrasound are seen in decompensated heart failure, but their diagnostic value in consecutive patients in the acute setting is not clear. Chest CT is the superior method to evaluate interstitial lung disease, but no studies have compared lung ultrasound directly to congestion on chest CT. PURPOSE To examine whether congestion on lung ultrasound equals congestion on a low-dose chest CT as the gold standard. MATERIALS AND METHODS In a single-center, prospective observational study we included consecutive patients ≥ 50 years of age in the emergency department. Patients were concurrently examined by lung ultrasound and chest CT. Congestion on lung ultrasound was examined in three ways: I) the total number of B-lines, II) ≥ 3 B-lines bilaterally, III) ≥ 3 B-lines bilaterally and/or bilateral pleural effusion. Congestion on CT was assessed by two specialists blinded to all other data. RESULTS We included 117 patients, 27 % of whom had a history of heart failure and 52 % chronic obstructive pulmonary disease. Lung ultrasound and CT were performed within a median time of 79.0 minutes. Congestion on CT was detected in 32 patients (27 %). Method I had an optimal cut-point of 7 B-lines with a sensitivity of 72 % and a specificity of 81 % for congestion. Method II had 44 % sensitivity, and 94 % specificity. Method III had a sensitivity of 88 % and a specificity of 85 %. CONCLUSION Pulmonary congestion in consecutive dyspneic patients ≥ 50 years of age is better diagnosed if lung ultrasound evaluates both B-lines and pleural effusion instead of B-lines alone.
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Affiliation(s)
- Kristina Cecilia Miger
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | - Christian Peter Maschmann
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
- Department of Anesthesiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Jesper Wamberg
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | | | - Lars Pedersen
- Department of Respiratory Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | - Janus Damm Nybing
- Department of Radiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Olav Wendelboe Nielsen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
- Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Kajal K, Premkumar M, Chaluvashetty SB, Bhujade H, Kulkarni AV. Point-of-Care Thoracic Ultrasonography in Patients With Cirrhosis and Liver Failure. Cureus 2021; 13:e15559. [PMID: 34277182 PMCID: PMC8271278 DOI: 10.7759/cureus.15559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/06/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) helps determine liver-related pathologies like an abscess, portal vein or hepatic vein thromboses, presence of ascites, site for pleural or ascitic paracentesis, and guiding biopsies. POCUS is revolutionizing the management of critically ill patients presenting with pneumonia, acute respiratory distress syndrome, acute-on-chronic liver failure, and in the emergency. The objectives of thoracic ultrasonography (TUS) are to aid the clinician in differentiating between pneumonia, effusions, interstitial edema and collections, and in estimating the volume status of patients with liver disease using inferior vena cava dynamic indices. The use of POCUS in patients with cirrhosis has since evolved. It is now widely used to help diagnose volume status, left ventricular diastolic dysfunction, myocardial infarction, and right ventricular dilation due to pulmonary embolism and to determine the causes for weaning failures such as effusions, lung collapse, and pneumothorax. During the Coronavirus Disease 2019 (COVID-19) pandemic, moving patients for computed tomography can be difficult. Therefore, TUS is now essential in liver transplantation and intensive care practice to assess ventilatory pressures, cardiac function, and fluid management. This review indicates the current and optimized use of TUS, offers a practical guide on TUS in the liver intensive care unit (ICU), and presents a diagnostic pathway for determining lung and pleural pathology, resolution of respiratory failure, and aid weaning from mechanical ventilation.
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Affiliation(s)
- Kamal Kajal
- Anesthesia and Critical Care, Post Graduate Institute of Medical Education & Research, Chandigarh, IND
| | - Madhumita Premkumar
- Hepatology, Post Graduate Institute of Medical Education & Research, Chandigarh, IND
| | | | - Harish Bhujade
- Radiodiagnosis, Post Graduate Institute of Medical Education & Research, Chandigarh, IND
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28
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Kim KH, Jung JY, Park JW, Lee MS, Lee YH. Operating bedside cardiac ultrasound program in emergency medicine residency: A retrospective observation study from the perspective of performance improvement. PLoS One 2021; 16:e0248710. [PMID: 33798217 PMCID: PMC8018668 DOI: 10.1371/journal.pone.0248710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Point-of-care ultrasound is one of useful diagnostic tools in emergency medicine practice and considerably depends on physician’s performance. This study was performed to evaluate performance improvements and favorable attitudes through structured cardiac ultrasound program for emergency medicine residents. Methods Retrospective observational study using the point-of-care ultrasound (PoCUS) database in one tertiary academic-teaching hospital emergency department has been conducted. Cardiac ultrasound education and rotation program has been implemented in emergency medicine residency program. Structured evaluation sheet for cardiac ultrasound and questionnaire toward PoCUS have been developed. An early-phase and a late-phase case were selected randomly for each participant. Two emergency medicine specialists with expertise in PoCUS evaluated saved images independently. We used a paired t-test to compare the performance score of each phase and the results of the questionnaire. Multivariable linear regression analysis was conducted to evaluate the association between the characteristics of participants and performance improvements. Results During the study period, a total of 1,652 bedside cardiac ultrasounds were administered. Forty-six examinations conducted by 23 emergency medicine residents were randomly selected for analysis. The performance score increased from 39.5 to 56.1 according to expert A and 45.3 to 62.9 according to expert B (p-value <0.01 for both). The average questionnaire score, which was analyzed for 17 participants, showed improvement from 18.9 to 20.7 (p-value <0.01). In multivariable linear regression analysis, younger age, higher early-phase score and higher confidence had a negative association with a greater improvement of performance, while the number of examinations had a positive association. Conclusions Bedside cardiac ultrasound performance and attitudes toward PoCUS have been improved through structured residency program.
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Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- * E-mail:
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yong Hee Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
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29
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Diagnostic performances of lung ultrasound associated with inferior vena cava assessment for the diagnosis of acute heart failure in elderly emergency patients: a diagnostic study. Eur J Emerg Med 2021; 28:119-124. [PMID: 33181535 DOI: 10.1097/mej.0000000000000759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND IMPORTANCE Few studies are looking at the usefulness of lung ultrasound combined with inferior vena cava (ultrasound strategy) in the particularly challenging diagnosis of acute heart failure (AHF) in elderly dyspneic patients attending the emergency department (ED). OBJECTIVE, DESIGN, SETTINGS, AND PARTICIPANTS This was a prospective diagnostic study conducted in two French EDs from December 2015 to March 2019, aimed to determine the accuracy of an ultrasound strategy for the diagnosis of AHF in the elderly. Patients aged 65 and older referred to the ED for dyspnea were screened for inclusion. INTERVENTION An emergency physician, blinded to the first findings, performed chest ultrasound, and assessment of inferior vena cava (ultrasound strategy). OUTCOME MEASURE AND ANALYSIS The primary endpoint was a final diagnosis of AHF, adjudicated by two independent experts after reviewing the entire medical record. The sensitivity and specificity of ultrasound and standard strategies were calculated. MAIN RESULTS A total of 116 patients were included, mean age 84 years (SD 9). Among them, there were 76 (66%) cases of AHF and 51 (44%) cases of pneumonia. The ultrasound work up had a sensitivity of 82% [95% confidence interval (CI), 71-90] and a specificity of 68% (95% CI, 51-90] for AHF. The standard strategy had a sensitivity of 92% (95% CI, 84-97) and a specificity of 53% (95% CI, (36-68). CONCLUSIONS In this prospective study, there was no statistically significant difference between point-of-care ultrasound and a combination of clinical, radiographic, and biological findings for the diagnosis of acute heart failure.
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30
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Gibbons RC, Magee M, Goett H, Murrett J, Genninger J, Mendez K, Tripod M, Tyner N, Costantino TG. Lung Ultrasound vs. Chest X-Ray Study for the Radiographic Diagnosis of COVID-19 Pneumonia in a High-Prevalence Population. J Emerg Med 2021; 60:615-625. [PMID: 33722414 PMCID: PMC7859730 DOI: 10.1016/j.jemermed.2021.01.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/22/2021] [Accepted: 01/31/2021] [Indexed: 02/07/2023]
Abstract
Background The viral illness severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as Coronavirus 2019 (COVID-19), has become a global pandemic, infecting over 100 million individuals worldwide. Objectives The objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia. Methods This was a single-center, prospective, observational study at an urban university hospital with > 105,000 patient visits annually. Patients ≥ 18 years old, who presented to the Emergency Department with predefined signs and symptoms of COVID-19, were eligible for enrollment. Each patient received an LUS using a portable, handheld ultrasound followed by a single-view, portable anteroposterior CXR. Patients with an abnormal LUS or CXR underwent a non-contrast-enhanced computed tomography scan (NCCT). The primary outcome was the radiographic diagnosis of COVID-19 pneumonia on NCCT. Results One hundred ten patients underwent LUS, CXR, and NCCT; 99 LUS and 73 CXRs were interpreted as positive; 81 NCCTs were interpreted as positive, providing a prevalence of COVID-19 pneumonia of 75% (95% confidence interval [CI] 66–83.2) in our study population. LUS sensitivity was 97.6% (95% CI 91.6–99.7) vs. 69.9% (95% CI 58.8–79.5) for CXR. LUS specificity was 33.3% (95% CI 16.5–54) vs. 44.4% (95% CI 25.5–64.7) for CXR. LUS positive predictive value and negative predictive value were 81.8% (95% CI 72.8–88.9) and 81.8% (95% CI 48.2–97.7), respectively, vs. 79.5% (95% CI 68.4–88), and 32.4% (95% CI 18–49.8), respectively, for CXR. Conclusion LUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia.
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Affiliation(s)
- Ryan C Gibbons
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mark Magee
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Harry Goett
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - James Murrett
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jessica Genninger
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Kendra Mendez
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Matthew Tripod
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Nicholas Tyner
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Thomas G Costantino
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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31
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Premkumar M, Kajal K, Kulkarni AV, Gupta A, Divyaveer S. Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era. J Intensive Care Med 2021; 36:511-523. [PMID: 33438491 DOI: 10.1177/0885066620988281] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V Kulkarni
- Department of Hepatology, 78470Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Ankur Gupta
- Department of Cardiology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Department of Nephrology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Squizzato A, Maroni L, Marrazzo C, Riva N, Guasti L. Diagnostic accuracy of inferior vena cava ultrasound for heart failure in patients with acute dyspnoea: a systematic review and meta-analysis. Emerg Med J 2020; 38:232-239. [PMID: 33298601 DOI: 10.1136/emermed-2019-208547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 10/15/2020] [Accepted: 11/11/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dyspnoea is the most common sign of heart failure (HF). Patients accessing the ED for HF-related symptoms require fast diagnosis and early treatment. Transthoracic echocardiography has a crucial role in HF diagnosis, but requires qualified staff and adequate time for execution. The measurement of inferior vena cava (IVC) diameter has been recently proposed as a rapid, simple and reliable marker of volume overload. The aim of this systematic review was to assess the accuracy of IVC-ultrasound as a stand-alone test for HF diagnosis in patients presenting to the ED with acute dyspnoea. METHODS Studies evaluating the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CIx) for HF diagnosis were systematically searched in the EMBASE and MEDLINE databases (up to January 2018). Quality Assessment of Diagnostic Accuracy Studies 2 tool was used for the quality assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity. RESULTS Seven studies, for a total of 591 patients, were included. Three studies were at low-risk of bias. All studies used a proper reference test. Weighted mean prevalence of HF was 49.3% at random-effect model (I2 index for heterogeneity=74.7%). IVC-CIx bivariate weighted mean sensitivity was 79.1% (95% CI 68.5% to 86.8%) and bivariate weighted mean specificity was 81.8% (95% CI 75.0% to 87.0%). CONCLUSIONS Our findings suggest that the sensitivity and specificity of IVC-CIx are suboptimal to rule in or rule out HF diagnosis in patients with acute dyspnoea in the ED setting. Therefore, IVC-CIx is not advisable as a stand-alone test, but may be useful when integrated in a specific diagnostic algorithm for the differential diagnosis of acute dyspnoea.
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Affiliation(s)
| | - Lorenzo Maroni
- Internal Medicine, Sant'Antonio Abate Hospital, Gallarate, Italy
| | | | | | - Luigina Guasti
- Medicine and Surgery, University of Insubria, Varese/Como, Italy
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Balderston JR, Sternberg ME, Joyce JM, Evans DP, Gertz ZM. Focused Cardiac Ultrasound in Dyspnea of Unclear Etiology in the Emergency Department: Utility of the FLUID Score. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2211-2217. [PMID: 32395861 DOI: 10.1002/jum.15332] [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: 12/26/2019] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We evaluated the utility of focused cardiac ultrasound to predict the length of stay in patients presenting to the emergency department with dyspnea of unclear etiology. METHODS Patients with focused cardiac ultrasound examinations performed in the emergency department for dyspnea over a 34-month period were retrospectively identified. Patients were excluded if they had a prior diagnosis of heart failure, dialysis requirement, or an etiology of dyspnea unrelated to the volume status. Left ventricular function was categorized as normal or reduced, and the inferior vena cava was categorized as normal or increased volume. A fast limited ultrasound to investigate dyspnea (FLUID) score was calculated by adding 1 point for reduced left ventricular function and 1 point for increased volume, producing a score of 0, 1, or 2. RESULTS There were 123 patients included. There was a significant correlation between the FLUID score and length of stay, with longer stays for higher scores (FLUID score 0, 7.4 hours median; FLUID score 1, 2.34 days; FLUID score 2, 5.56 days; analysis of variance P < .001). Of the other variables collected, only age, hypertension, diabetes, heart rate, and brain natriuretic peptide were significantly correlated with the length of stay. A multivariate analysis including those variables and the FLUID score showed that the FLUID score was the strongest independent predictor of the length of stay. CONCLUSIONS Focused cardiac ultrasound and calculation of a FLUID score for patients with undifferentiated dyspnea can be a powerful tool to predict the hospital length of stay.
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Affiliation(s)
- Jessica R Balderston
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael E Sternberg
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - J Michael Joyce
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David P Evans
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
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Hsu P, Shepherd C, Shokraneh K, Cabrera G, Kalivoda EJ. Emergent Diagnosis of a Flail Mitral Leaflet With Bedside Echocardiography. Cureus 2020; 12:e9374. [PMID: 32850242 PMCID: PMC7444964 DOI: 10.7759/cureus.9374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Russell FM, Ferre R, Ehrman RR, Noble V, Gargani L, Collins SP, Levy PD, Fabre KL, Eckert GJ, Pang PS. What are the minimum requirements to establish proficiency in lung ultrasound training for quantifying B-lines? ESC Heart Fail 2020; 7:2941-2947. [PMID: 32697034 PMCID: PMC7524048 DOI: 10.1002/ehf2.12907] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/22/2020] [Accepted: 06/30/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS The goal of this study was to determine the number of scans needed for novice learners to attain proficiency in B-line quantification compared with expert interpretation. METHODS AND RESULTS This was a prospective, multicentre observational study of novice learners, physicians and non-physicians from three academic institutions. Learners received a 2 h lung ultrasound (LUS) training session on B-line assessment, including lecture, video review to practice counting and hands-on patient scanning. Learners quantified B-lines using an eight-zone scanning protocol in patients with suspected acute heart failure. Ultrasound (US) machine settings were standardized to a depth of 18 cm and clip length of 6 s, and tissue harmonics and multibeam former were deactivated. For quantification, the intercostal space with the greatest number of B-lines within each zone was used for scoring. Each zone was given a score of 0-20 based on the maximum number of B-lines counted during one respiratory cycle. The B-line score was determined by multiplying the percentage of the intercostal space filled with B-lines by 20. We compared learner B-line counts with a blinded expert reviewer (five US fellowship-trained faculty with > 5 years of clinical experience) for each lung zone scanned; proficiency was defined as an intraclass correlation of > 0.7. Learning curves for each learner were constructed using cumulative sum method for statistical analysis. The Wilcoxon rank-sum test was used to compare the number of scans required to reach proficiency between different learner types. Twenty-nine learners (21 research associates, 5 residents and 3 non-US-trained emergency medicine faculty) scanned 2629 lung zones with acute pulmonary oedema. After a mean of 10.8 (standard deviation 14.0) LUS zones scanned, learners reached the predefined proficiency standard. The number of scanned zones required to reach proficiency was not significantly different between physicians and non-physicians (P = 0.26), learners with no prior US experience vs. > 25 prior patient scans (P = 0.64) and no prior vs. some prior LUS experience (P = 0.59). The overall intraclass correlation for agreement between learners and experts was 0.74 and 0.80 between experts. CONCLUSIONS Our results show that after a short, structured training, novice learners are able to achieve proficiency for quantifying B-lines on LUS after scanning 11 zones. These findings support the use of LUS for B-line quantification by non-physicians in clinical and research applications.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robinson Ferre
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Vicki Noble
- Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - George J Eckert
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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House DR, Amatya Y, Nti B, Russell FM. Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal. Int J Emerg Med 2020; 13:14. [PMID: 32245366 PMCID: PMC7118827 DOI: 10.1186/s12245-020-00273-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/20/2020] [Indexed: 12/21/2022] Open
Abstract
Background Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal. Methods A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management. Results Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%). Conclusions In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.
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Affiliation(s)
- Darlene R House
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal. .,Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
| | - Yogendra Amatya
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Benjamin Nti
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
| | - Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
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Farahmand S, Abdolhoseini A, Aliniagerdroudbari E, Babaniamansour S, Baratloo A, Bagheri-Hariri S. Point-of-care ultrasound modalities in terms of diagnosing acute decompensated heart failure in emergency department; a diagnostic accuracy study. Intern Emerg Med 2020; 15:491-499. [PMID: 31786750 DOI: 10.1007/s11739-019-02233-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/08/2019] [Indexed: 11/27/2022]
Abstract
This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard. The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014-2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure. A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF) < 45% has the highest sensitivity. The combination of LVEF and IVC collapsibility index (IVC-CI), LVEF and BLC, IVC-CI and BLC, and IVC-CI and BBPC had a higher specificity rate and combination of LVEF and BBPC and BLC and BBPC had the highest sensitivity. Sensitivity, specificity, positive predictive value and negative predictive value of all three ultrasounds combined were 31.6%, 98.4%, 94.7% and 61.4%, respectively. In this study, the diagnostic accuracy of double and triple ultrasonography of heart, lung and IVC in the diagnosis of ADHF was very high, among which triple ultrasonography was more preferable.
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Affiliation(s)
- Shervin Farahmand
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Abdolhoseini
- Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Alireza Baratloo
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahram Bagheri-Hariri
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Ecografía clínica en el proceso de toma de decisiones en medicina. Rev Clin Esp 2020; 220:49-56. [DOI: 10.1016/j.rce.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 02/02/2023]
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García de Casasola G, Casado López I, Torres-Macho J. Clinical ultrasonography in the decision-making process in medicine. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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40
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Picano E, Scali MC, Ciampi Q, Lichtenstein D. Lung Ultrasound for the Cardiologist. JACC Cardiovasc Imaging 2019; 11:1692-1705. [PMID: 30409330 DOI: 10.1016/j.jcmg.2018.06.023] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 02/06/2023]
Abstract
For a cardiologist, lung ultrasound is an add-on to transthoracic echocardiography, just as lung auscultation is part of a cardiac physical examination. A cardiac 3.5- to 5.0-MHz transducer is generally suitable because the small footprint makes it ideal for scanning intercostal spaces. The image quality is often adequate, and the lung acoustic window is always patent. The cumulative increase in imaging time is <1 min for the 2 main applications targeted on pleural water (pleural effusion) and lung water (pulmonary congestion as multiple B-lines). In these settings, lung ultrasound outperforms the diagnostic accuracy of the chest radiograph, with a low-cost, portable, real-time, radiation-free method. A "wet lung" detected by lung ultrasound predicts impending acute heart failure decompensation and may trigger lung decongestion therapy. The doctors of tomorrow may still listen with a stethoscope to their patient's lung, but they will certainly be seeing it with ultrasound.
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Affiliation(s)
| | | | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Daniel Lichtenstein
- Medical Intensive Care Unit, Ambroise-Paré Hospital, Paris-West University, Boulogne, France
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Long B, Koyfman A, Gottlieb M. Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. West J Emerg Med 2019; 20:875-884. [PMID: 31738714 PMCID: PMC6860389 DOI: 10.5811/westjem.2019.9.43732] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Abstract
PURPOSE OF REVIEW Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present. RECENT FINDINGS AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.
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Baker K, Brierley S, Kinnear F, Isoardi K, Livesay G, Stieler G, Mitchell G. Implementation study reporting diagnostic accuracy, outcomes and costs in a multicentre randomised controlled trial of non‐expert lung ultrasound to detect pulmonary oedema. Emerg Med Australas 2019; 32:45-53. [DOI: 10.1111/1742-6723.13333] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Kylie Baker
- Department of Emergency MedicineIpswich General Hospital Ipswich Queensland Australia
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Stephen Brierley
- Department of Emergency MedicineIpswich General Hospital Ipswich Queensland Australia
| | - Frances Kinnear
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
- Department of Emergency MedicineThe Prince Charles Hospital Brisbane Queensland Australia
| | - Katherine Isoardi
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
- Department of Emergency MedicinePrincess Alexandra Hospital Brisbane Queensland Australia
| | - Georgia Livesay
- Department of Emergency MedicinePrincess Alexandra Hospital Brisbane Queensland Australia
| | - Geoffrey Stieler
- Department of RadiologyIpswich General Hospital Ipswich Queensland Australia
| | - Geoffrey Mitchell
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
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Nair S, Sauthoff H. Assessing Extravascular Lung Water With Ultrasound: A Tool to Individualize Fluid Management? J Intensive Care Med 2019; 35:1356-1362. [PMID: 31167585 DOI: 10.1177/0885066619855000] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Aggressive fluid resuscitation has become standard of care for hypotensive patients with sepsis. However, sepsis is a syndrome that occurs in patients with diverse underlying physiology and a one-size-fits-all approach to fluid administration seems misguided. To individualize fluid management, several methods to assess fluid responsiveness have been validated, but even in fluid responsive patients, fluid administration may still be harmful and lead to pulmonary edema. Hence, to individualize fluid management, in addition to fluid responsiveness, fluid tolerance needs to be assessed. This article examines whether lung ultrasound can be useful to detect excess extravascular lung water (EVLW) and thus assess fluid tolerance. The physiology of EVLW and the principles of lung ultrasound are briefly described. Articles examining the correlation between EVLW and lung ultrasound findings in various clinical settings are carefully reviewed. Overall, lung ultrasound has been found to be an excellent tool to detect EVLW, but large outcome studies investigating lung ultrasound-guided fluid management are still lacking.
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Affiliation(s)
- Sunil Nair
- Division of Pulmonary and Critical Care Medicine, 12297NYU School of Medicine, New York, NY, USA
| | - Harald Sauthoff
- Division of Pulmonary and Critical Care Medicine, 12297NYU School of Medicine, New York, NY, USA.,12297VA New York Harbor Healthcare System, New York, NY, USA
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Seetharam K, Kagiyama N, Sengupta PP. Application of mobile health, telemedicine and artificial intelligence to echocardiography. Echo Res Pract 2019; 6:R41-R52. [PMID: 30844756 PMCID: PMC6432977 DOI: 10.1530/erp-18-0081] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 02/20/2019] [Indexed: 01/20/2023] Open
Abstract
The intersection of global broadband technology and miniaturized high-capability computing devices has led to a revolution in the delivery of healthcare and the birth of telemedicine and mobile health (mHealth). Rapid advances in handheld imaging devices with other mHealth devices such as smartphone apps and wearable devices are making great strides in the field of cardiovascular imaging like never before. Although these technologies offer a bright promise in cardiovascular imaging, it is far from straightforward. The massive data influx from telemedicine and mHealth including cardiovascular imaging supersedes the existing capabilities of current healthcare system and statistical software. Artificial intelligence with machine learning is the one and only way to navigate through this complex maze of the data influx through various approaches. Deep learning techniques are further expanding their role by image recognition and automated measurements. Artificial intelligence provides limitless opportunity to rigorously analyze data. As we move forward, the futures of mHealth, telemedicine and artificial intelligence are increasingly becoming intertwined to give rise to precision medicine.
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Affiliation(s)
- Karthik Seetharam
- West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
| | - Nobuyuki Kagiyama
- West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
| | - Partho P Sengupta
- West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
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Riishede M, Laursen CB, Teglbjærg LS, Rancinger E, Pedersen PB, Luef SM, Clausen JH, Graumann O, Lassen AT, Baatrup G. Diagnostic value of whole-body-focused ultrasonography in high-acuity patients in the emergency department: a prospective single-center cross-sectional study. Ultrasound J 2019; 11:11. [PMID: 31359192 PMCID: PMC6638611 DOI: 10.1186/s13089-019-0126-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/20/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND A fast and diagnostic accurate tool to assess the unselected category of high-acuity patients, in whom the underlying pathology is not always obvious, is needed in the emergency departments (ED). We aim to describe the feasibility, validity and diagnostic yield of a routine whole-body-focused ultrasonography (wbf-us) in an unselected group of high-acuity ED patients. METHODS In a prospective observational study, a convenience sample of ED patients (≥ 18 years) with a high-acuity score or systolic blood pressure < 100 mmHg received a routine wbf-us of the heart, lungs, abdomen and deep veins by two non-expert sonographers. Final diagnosis was established by experienced auditors. Investigators were blinded to the patients' medical history and emergency physicians and auditors were blinded to the investigators assessments. Diagnostic accuracy was assessed by comparing the investigators' ultrasonography findings to a structured double-blinded clinical audit of patient files. RESULTS We included 171 patients, initiated a whole-body-focused ultrasonography examination (wbf-us) in 160 and completed it in 128 patients with an average time of a full examination of 28 min. We found pathology in 65/171 (38%) of the patients whose most frequent symptoms upon arrival were cardiopulmonary. Among the patients who received wbf-us, we found the majority of pathology by wbf-us of the lungs (n = 50, 31%), the heart (n = 26, 16%), few in the abdomen (n = 5, 3%) and none in the deep veins. The overall sensitivity was 50-100%, specificity 84-94%, positive predictive value 11-44% and negative predictive value 94-100%. CONCLUSION Focused cardiopulmonary ultrasonography might be considered for routine use in high-acuity ED patients with cardiopulmonary symptoms whereas focused ultrasonography of the abdomen and deep veins performed by non-expert sonographers only seems indicated in selected patients. Trial registration Danish Data Protection Agency (ID 13/12076). Committee on Biomedical Research Ethics for the Region of Southern Denmark (ID S-20130047).
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Affiliation(s)
- M Riishede
- The Research Section, Department of Surgery (A), Odense University Hospital, Baagoes Allé 15, 5700, Svendborg, Denmark. .,Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark. .,Department of Internal Medicine & Emergency Medicine (M/FAM), Odense University Hospital, Svendborg, Denmark.
| | - C B Laursen
- Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark.,Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - L S Teglbjærg
- Department of Internal Medicine & Emergency Medicine (M/FAM), Odense University Hospital, Svendborg, Denmark
| | - E Rancinger
- The Research Section, Department of Surgery (A), Odense University Hospital, Baagoes Allé 15, 5700, Svendborg, Denmark
| | - P B Pedersen
- Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark.,Department of Internal Medicine & Emergency Medicine (M/FAM), Odense University Hospital, Svendborg, Denmark
| | - S M Luef
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - J H Clausen
- Department of Cardiology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - O Graumann
- Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark.,Department of Radiology, Odense University Hospital, Odense, Denmark
| | - A T Lassen
- Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark.,Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - G Baatrup
- The Research Section, Department of Surgery (A), Odense University Hospital, Baagoes Allé 15, 5700, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, SDU, Odense, Denmark
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Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department. Eur J Emerg Med 2019; 26:112-117. [PMID: 28984662 DOI: 10.1097/mej.0000000000000499] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the performance of a rapid cardiothoracic ultrasound protocol (CaTUS), combining echocardiographically derived E/e' and lung ultrasound (LUS), for diagnosing acute heart failure (AHF) in patients with undifferentiated dyspnea in an emergency department (ED). PATIENTS AND RESULTS We enrolled 100 patients with undifferentiated dyspnea from a tertiary care ED, who all had CaTUS done immediately upon arrival in the ED. CaTUS was positive for AHF with an E/e' > 15 and congestion, that is bilateral B-lines or bilateral pleural fluid, on LUS. In addition, an inferior vena cava index was also recorded to analyze whether including a central venous pressure estimate would add diagnostic benefit to the CaTUS protocol. All 100 patients had a brain natriuretic peptide (BNP) sample withdrawn, and 96 patients underwent chest radiography in the ED, which was analyzed later by a blinded radiologist. The reference diagnosis of AHF consisted of either a BNP of more than 400 ng/l or a BNP of less than 100 ng/l in combination with congestion on chest radiography and structural heart disease on conventional echocardiography.CaTUS had a sensitivity of 100% (95% confidence interval: 91.4-100%), a specificity of 95.8% (95% confidence interval: 84.6-99.3%), and an area under the curve of 0.979 for diagnosing AHF (P<0.001). The diagnostic accuracy of CaTUS was higher than of either E/e' or LUS alone. Adding the inferior vena cava index to CaTUS did not improve diagnostic accuracy. CaTUS seemed helpful also for differential diagnostics of dyspnea, mainly regarding pneumonias and pulmonary embolisms. CONCLUSION CaTUS, combining E/e' and LUS, provided excellent accuracy for diagnosing AHF.
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Dehbozorgi A, Eslami Nejad S, Mousavi-Roknabadi RS, Sharifi M, Tafakori A, Jalli R. Lung and cardiac ultrasound (LuCUS) protocol in diagnosing acute heart failure in patients with acute dyspnea. Am J Emerg Med 2019; 37:2055-2060. [PMID: 30833043 DOI: 10.1016/j.ajem.2019.02.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To investigate the accuracy of lung and cardiac ultrasound (LuCUS) protocol in diagnosing Acute Heart Failure (AHF) in patients who refer to Emergency Department (ED) with acute dyspnea. METHODS This was an interventional study on adult patients, who were referred with chief complaint of undifferentiated acute dyspnea to the ED of Namazi hospital, the largest referral center in southern Iran. The intervention was LuCUS protocol, which was performed by Emergency Physicians (EPs) at the bedside. All patients' files were reviewed separately by two independent specialists, who were blinded to LuCUS results for final diagnosis as gold standard, then the results of LuCUS were compared with it. All data were analyzed and diagnostic tests were calculated (α = 0.05). RESULTS In 100 patients enrolled in the study, 28% had the final diagnosis as AHF. The LuCUS protocol had the sensitivity of 64% (95%CI, 44%-81%), specificity of 97% (95%CI, 90%-100%), positive predicative value of 90% (95%CI, 69%-97%), negative predicative value of 88% (95%CI, 81%-92%), positive likelihood ratio of 23.14 (95%CI, 5.74-93.3), negative likelihood ratio of 0.37 (95%CI, 0.22-0.6), and accuracy of 88% (95%CI, 80%-94%). CONCLUSION LuCUS protocol can be used by EPs as a practical tool to differentiate the cardiac and non-cardiac etiologies of acute dyspnea, specifically AHF, as it is more accurate than clinical diagnosis by itself. Hence, it is recommend that while conducting further studies in order to achieve more generalizable results, EPs can employ it alongside their clinical evaluations to have a faster and more accurate diagnosis.
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Affiliation(s)
- Afsaneh Dehbozorgi
- Emergency Medicine Department, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.
| | - Saman Eslami Nejad
- Emergency Medicine Department, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | - Razieh Sadat Mousavi-Roknabadi
- Emergency Medicine Department, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.
| | - Mehrdad Sharifi
- Emergency Medicine Department, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | - Azadeh Tafakori
- Emergency Medicine Department, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.
| | - Reza Jalli
- Medical Imaging Research Center, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.
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Muniz RT, Mesquita ET, Souza Junior CV, Martins WDA. Pulmonary Ultrasound in Patients with Heart Failure - Systematic Review. Arq Bras Cardiol 2019; 110:577-584. [PMID: 30226917 PMCID: PMC6023636 DOI: 10.5935/abc.20180097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Abstract
Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied.
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Affiliation(s)
- Rafael Tostes Muniz
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil.,Complexo Hospitalar de Niterói, Niterói, RJ - Brazil
| | - Evandro Tinoco Mesquita
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil
| | | | - Wolney de Andrade Martins
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil.,Complexo Hospitalar de Niterói, Niterói, RJ - Brazil
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The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis. CAN J EMERG MED 2019; 21:406-417. [PMID: 30696496 DOI: 10.1017/cem.2018.498] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department. METHODS Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock. RESULTS A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock. CONCLUSION The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.
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