How fast is the focused assessment with sonography for trauma examination learning curve?

Diagnostic accuracy for hemoperitoneum, influence on prehospital times and time-to-definitive treatment of prehospital FAST: A systematic review and individual participant data meta-analysis

BACKGROUND

Focused assessment sonography for trauma (FAST) performed in the prehospital setting may improve trauma care by influencing treatment decisions and reducing time to definitive care, but its accuracy and benefits remain uncertain. This systematic review evaluated the diagnostic accuracy of prehospital FAST in detecting hemoperitoneum and its effects on prehospital time and time to definitive diagnosis or treatment.

METHODS

We systematically searched PubMed, Embase, and Cochrane library up to November 11th, 2022. Studies investigating prehospital FAST and reporting at least one outcome of interest for this review were considered eligible. The primary outcome was prehospital FAST diagnostic accuracy for hemoperitoneum. A random-effect meta-analysis, including individual patient data, was performed to calculate the pooled outcomes with 95% confidence intervals (CI). Quality of studies was assessed using the QUADAS-2 tool for diagnostic accuracy.

RESULTS

We included 21 studies enrolling 5790 patients. The pooled sensitivity and specificity of prehospital FAST for hemoperitoneum were 0.630 (0.454 - 0.777) and 0.970 (0.957-0.979), respectively. Prehospital FAST was performed in a median of 2.72 (2.12 - 3.31) minutes without increasing prehospital times (pooled median difference of 2.44 min [95% CI: -3.93 - 8.81]) compared to standard management. Prehospital FAST findings changed on-scene trauma care in 12-48% of cases, the choice of admitting hospital in 13-71%, the communication with the receiving hospital in 45-52%, and the transfer management in 52-86%. Patients with a positive prehospital FAST achieved definitive diagnosis or treatment more rapidly (severity-adjusted pooled time ratio = 0.63 [95% CI: 0.41 - 0.95]) compared with patients with a negative or not performed prehospital FAST.

CONCLUSIONS

Prehospital FAST had a low sensitivity but a very high specificity to identify hemoperitoneum and reduced time-to-diagnostics or interventions, without increasing prehospital times, in patients with a high probability of abdominal bleeding. Its effect on mortality is still under-investigated.

Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound

Purpose

The learning curve of nurse practitioners (NPs) to accurately diagnose paediatric distal forearm fractures using point-of-care ultrasound (POCUS) was investigated.

Methods

Each NP's learning curve was calculated as cumulative diagnostic accuracy against a number of scans performed. The curve's plateau represented the attainment of competency. Secondary outcomes were the comparisons before and after this cut-off of diagnostic accuracy, classification of diagnostic errors, pain scores, duration and preference.

Results

Five NPs performed 201 POCUS studies with diagnostic accuracy plateauing at 90%, providing a 'cut-off' point at scan 15. Accuracy of POCUS scanning before and after the fifteenth scan was 81% (95% CI 70%-89%) and 90% (95% CI 84%-94%), respectively, demonstrating 9% improvement (P = 0.07). There was a 10% reduction in image interpretation errors. After fifteen scans, POCUS became faster (mean difference (MD) 2.6 min [95% CI 2.0-3.3], P < 0.001), less painful (MD 0.61 points FPSR scale [95% CI 0.04-1.18], P = 0.04) and more preferred by NPs (63% vs 77%, P = 0.03).

Discussion

The learning curve of POCUS-novice NPs independently scanning paediatric distal forearm injuries plateaued with mean diagnostic accuracy of 90% after 15 scans, suggesting competency was attained at this cut-off, supported by higher accuracy, being faster, less painful and more preferred by NPs. Future training packages in forearm POCUS should further address image interpretation and provide ongoing expert feedback.

Conclusions

The findings from this study suggest that competency in paediatric distal forearm POCUS can be attained by novices after a short training course and approximately 15 scans.

Differences in training among prehospital emergency physicians in Germany

Background

Germany has an interdisciplinary physician-based emergency medical service. Differences in training likely lead to different levels of expertise.

Objectives

We assessed the number of manual procedures performed at the completion of training to determine level of experience of prehospital emergency physicians of different primary specialties.

Materials and methods

Immediately after passing the board examination each examinee was asked to estimate the number of performed procedures for 26 manual skills. We compared the results with recommendations and data on learning manual skills. Results are presented as mean (standard deviation).

Results

Endotracheal intubation via direct laryngoscopy was performed 1032 (739) times by anesthesiologists. Surgeons and internists performed 89 (89) and 77 (65) intubations, respectively. Intubation via video laryngoscopy was performed 79 (81) times by anesthesiologists, 11 (17) times by surgeons and 6 (11) times by internists. Surgeons had little experience in non-invasive ventilation, with 9 (19) performed procedures and had rarely used external pacemaker therapy or electrical cardioversion. In comparison, among all participants non-invasive ventilation was performed 152 (197) times, electrical cardioversion was performed 41 (103) times and an external pacemaker was used 6 (15) times. For other procedures the numbers did not markedly differ between the different specialties.

Conclusion

The number of performed procedures markedly differed for some skills between different primary specialties. Recommendations regarding a procedural volume were not always met, suggesting missing expertise for some skills. A defined number of procedures should therefore be a formal requirement to be eligible for board certification in prehospital emergency medicine.

Hands-On Time in Simulation-Based Ultrasound Training - A Dose-Related Response Study

Purpose Point of care ultrasound (POCUS) is widely used, but the sensitivity and specificity of the findings are highly user-dependent. There are many different approaches to ultrasound training. The aim of this study was to explore the effects of hands-on practice when learning POCUS. Methods Junior doctors with no or limited ultrasound experience were included in the study and divided into three groups. They all completed a Focused Assessment with Sonography for Trauma (FAST) course with different amounts of hands-on practice: 40 minutes (n=67), 60 minutes (n=12), and 90 minutes of hands-on time (n=27). By the end of the course, they all completed a previously validated test. Results More hands-on time improved the mean test scores and decreased the test time. The scores of the 40-, 60-, and 90-minute groups were 11.6 (SD 2.1), 12.8 (SD 2.5), and 13.7 (SD 2.5), respectively (p<0.001). The 90-minute group completed the test significantly faster than the other two groups (20 versus 26 minutes, p=0.003). A large inter-individual variation was seen. Conclusion The necessary amount of hands-on training is unknown. This study demonstrates that performance increases with prolonged hands-on time but the inter-individual variation among trainees is very large, thereby making it impossible to define the "optimal" time. This supports the use of the concept of mastery learning where each individual trainee can continue training until proficiency is reached.

Focused Assessment with Sonography for Trauma (FAST) training for first-year resident physicians at a university hospital in Japan: A longitudinal, observational study

Background:

Ultrasound training is an essential part of residency programs during emergency medicine rotations for first-year trainees (postgraduate year 1). The Focused Assessment with Sonography for Trauma examination used to assess for internal bleeding in trauma patients is one of the essential skills postgraduate year 1 residents must acquire during the emergency medicine rotation.

Method:

A prospective, longitudinal, observational study of postgraduate year 1 residents during a 2-month long emergency medicine rotation conducted from 1 April 2019 to 31 May 2021. The primary outcome was the mean difference between the hands-on Focused Assessment with Sonography for Trauma examination scores of the first week of the emergency medicine rotation and the same hands-on Focused Assessment with Sonography for Trauma examination scores of the last week of the emergency medicine rotation. All postgraduate year 1 residents had open access to the ultrasound machine to practice examining on other postgraduate year 1 residents or could use it on real patients under supervision of emergency medicine physicians.

Result:

A total of 91 postgraduate year 1 residents (65 male and 26 female) were recruited and submitted to the hands-on Focused Assessment with Sonography for Trauma test in both the first and last weeks of the rotation. The mean test score for the postgraduate year 1 residents in the first week was 7.81 (standard deviation = 2.11). The mean test score in the last week was 16.17 (standard deviation = 2.60). The primary outcome of this study was the score difference between the first and last weeks (mean = 8.35, 95% confidence interval = 7.73 to 8.94, p < 0.001, paired t-test).

Conclusion:

Hands-on practical Focused Assessment with Sonography for Trauma training for postgraduate year 1 residents during emergency medicine rotations significantly improved their Focused Assessment with Sonography for Trauma test scores.

Fifteen-minute consultation: Point of care ultrasound in the management of paediatric shock

The use of point of care ultrasound (POCUS) in the assessment of the acutely shocked adult patient has been well established for over a decade. Comparatively, its use in paediatrics has been limited, but this is starting to change with the recent introduction of Children's Acute Ultrasound training. This article highlights the pathophysiology of shock in children and demonstrates how bedside ultrasound can be used to assist decision making in the clinical assessment of the neonate, infant or older child presenting with undifferentiated shock. We discuss a structured protocol to use when performing the POCUS examination and explain how this could lead to a more rapid correlation of the ultrasound findings with the underlying cause of shock.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Use of Focused Assessment with Sonography in Trauma Examination Skills in the Evaluation of Non-trauma Patients

Study objectives

Although the focused assessment with sonography in trauma (FAST) examination was initially developed for rapid evaluation of trauma patients, the basic skillset required to perform a FAST examination provides valuable information that may alter a non-trauma patient’s clinical course. The objective of this study was to determine the utility of the FAST examination in the emergency department management of non-trauma patients.

Methods

Cases in which the FAST examination was used to direct care in non-trauma patients were retrospectively reviewed. Following the completion of the patient's care, emergency physicians were asked to complete a questionnaire indicating how information from the FAST examination was utilized to direct care of their non-trauma patients.

Results

A total of 63 non-trauma cases with average age of 48 years (range 16-94 years) were enrolled. The FAST examination positively impacted care in 57/63 (90.5%) cases. In 18/63 (28.6%) cases, the patient’s ultimate disposition changed because of FAST examination findings. In 9/63 (14.3%) cases, paracentesis was avoided by obtaining a FAST examination, and in 8/63 cases (12.7%) paracentesis was performed due to FAST examination results. In 16/63 (25.4%) cases, anticipated imaging changed due to FAST examination findings and 4/63 (6.3%) cases did not receive the anticipated computed tomography (CT) scan.

Conclusions

Although initially developed for evaluation of trauma patients, the FAST examination can provide valuable information that can positively impact care in non-trauma patients. The FAST examination can provide information to determine appropriate patient disposition, obtain appropriate additional imaging, ensure timely consultation, and eliminate risk from unnecessary procedures.

Focused assessment with sonography in trauma: a review of concepts and considerations for anesthesiology

The use of point-of-care ultrasound in trauma provides diagnostic clarity and routinely influences management. A scanning protocol known as the Focused Assessment with Sonography in Trauma (FAST) has been widely adopted by trauma providers of all specialties. The FAST exam addresses a broad array of pathologic conditions capable of causing instability, including hemoperitoneum, hemopericardium, hemothorax, and pneumothorax. The exam is an integral component to the primary assessment of injured patients and an iconic application of point-of-care ultrasound.This review article aims to summarize the application of the FAST exam with special consideration, where relevant, to anesthesiologists. The scope of the FAST exam, technical considerations, and clinical decision-making in trauma are explored.

Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.

Aeromedical Ultrasound: The Evaluation of Point-of-care Ultrasound During Helicopter Transport

INTRODUCTION

This study correlated the eFAST findings performed in-flight by the flight crew with the findings obtained by the trauma team upon initial evaluation at a level 1 trauma center and with the subsequent CT scans that were performed or the surgeon's operative note. We hypothesize that aeromedical eFAST examinations are highly correlated with the trauma teams findings.

METHODS

This prospective, observational study evaluated 190 traumatically injured patients from June 2014 to December 2015 in Southeast Virginia and Northeast North Carolina.

RESULTS

For 190 trauma patients the Flight Crew POCUS examinations obtained a Positive Predictive Value (PPV) of 100% and a Negative Predictive Value (NPV) of 98.3% for the identification of pneumothorax, hemothorax, and free abdominal fluid, which is equivalent to that of the Trauma Team's POCUS studies on the same group of patients.

DISCUSSION

Because the early recognition of potentially life-threatening conditions is critical to providing appropriate care to the traumatically injured patient this study provides solid statistical data that flight crews can adequately perform and interpret POCUS results as well as out trauma team colleagues. This study could lead to a reduction of iatrogenic injuries from unnecessary invasive prehospital procedures, allow for early initiation of Massive Transfusion Protocols (MTP) prior to the patient's arrival at the Trauma Center, and potentially develop a change in trauma systems notification and transportation directly to the operating room.

CONCLUSION

Despite this study developing a very positive outlook on performing aeromedical POCUS for the evaluation and care of trauma patients additional research will be required to better understand the potential impact on trauma activation protocols and activation of in-hospital resources.

Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava

BACKGROUND

Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology.

METHODS

Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively.

RESULTS

We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %.

CONCLUSIONS

This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation.

Chest Abdominal-Focused Assessment Sonography for Trauma during the primary survey in the Emergency Department: the CA-FAST protocol

PURPOSE

To evaluate the feasibility of a new protocol, Chest Abdominal-Focused Assessment Sonography for Trauma (CA-FAST), during the primary survey and to estimate its diagnostic accuracy when compared with thoracoabdominal computed tomography (CT) scan.

METHODS

A prospective accuracy study was performed from November 2012 to November 2013 at the Emergency Department. Only adult trauma patients who underwent a CA-FAST examination prior to a thoracoabdominal CT scan were enrolled. In addition to standard patterns detected by Extended-FAST (E-FAST) such as pneumothorax (PTX), hemothorax (HTX), pericardial and intraabdominal effusion, CA-FAST protocol also included the research of lung contusions (LCs).

RESULTS

Six hundred and one patients were enrolled. The mean time for protocol execution was 7 ± 3 min. Chest ultrasonography showed the following results (all p < 0.001): LCs sensitivity 59 %, specificity 98 %, positive predictive value (PPV) 92 %, negative predictive value (NPV) 86 %, accuracy 87 %; PTX sensitivity 84 %, specificity 98 %, PPV 93 %, NPV 95 %, accuracy 95 %; HTX sensitivity 82 %, specificity 97 %, PPV 87 %, NPV 95 %, accuracy 94 %. The standard 4-views FAST examination showed a diagnostic accuracy of 91 % with a sensitivity of 75 %, specificity of 96 %, PPV of 81 % and NPV of 94 %.

CONCLUSION

According to our results CA-FAST protocol proved to be a rapid bedside method, with good accuracy and high NPV in detection of ultrasonographic patterns suggestive of serious injury in trauma patients; moreover, the additional research of LCs did not cause a delay in the diagnosis. Ultrasonography should be used as initial investigation during the primary survey, sending to further diagnostic studies (CT scan) only those patients not clearly classified.

In-flight ultrasound identification of pneumothorax

Ultrasound is a standard adjunct to the initial evaluation of injured patients in the emergency department. We sought to evaluate the ability of prehospital, in-flight thoracic ultrasound to identify pneumothorax. Non-physician aeromedical providers were trained to perform and interpret thoracic ultrasound. All adult trauma patients and adult medical patients requiring endotracheal intubation underwent both in-flight and emergency department ultrasound evaluations. Findings were documented independently and reviewed to ensure quality and accuracy. Results were compared to chest X-ray and computed tomography (CT). One hundred forty-nine patients (136 trauma/13 medical) met inclusion criteria. Mean age was 44.4 (18-94) years; 69 % were male. Mean injury severity score was 17.68 (1-75), and mean chest injury score was 2.93 (0-6) in the injured group. Twenty pneumothoraces and one mainstem intubation were identified. Sixteen pneumothoraces were correctly identified in the field. A mainstem intubation was misinterpreted. When compared to chest CT (n = 116), prehospital ultrasound had a sensitivity of 68 % (95 % confidence interval (CI) 46-85 %), a specificity of 96 % (95 % CI 90-98 %), and an overall accuracy of 91 % (95 % CI 85-95 %). In comparison, emergency department (ED) ultrasound had a sensitivity of 84 % (95 % CI 62-94 %), specificity of 98 % (95 % CI 93-99 %), and an accuracy of 96 % (95 % CI 90-98 %). The unique characteristics of the aeromedical environment render the auditory element of a reliable physical exam impractical. Thoracic ultrasonography should be utilized to augment the diagnostic capabilities of prehospital aeromedical providers.

From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

Assessment of the numbers-based model for evaluation of resident competency in emergency ultrasound core applications

Background: The objective of this study was to assess the current numbers-based model of evaluation of emergency medicine residents in emergency ultrasound, specifically by focusing on the proficiency of residents to interpret right upper quadrant, focused abdominal sonogram for trauma, abdominal aorta, first trimester pregnancy, and cardiac scans. Methods: A prospective analysis of emergency medicine residents' competency in emergency ultrasound was conducted in 2009 and 2010. Residents completed a multiple choice style examination primarily assessing residents' diagnostic accuracy. The accuracy and confidence of diagnosis for each resident based on the examinations were compared to his/her training level and number of scans per application completed prior to testing, in order to assess the relationship of experience to competence. Results: Thirty-six emergency medicine residents, postgraduate year 1–3 (n = 15, 8, 13), were enrolled in the study and took the exam. There was a statistically significant relationship between the number of scans and mean exam score for right upper quadrant (p = 0.0013) and abdominal aorta (p = 0.0013) scans. Residents demonstrated a statistically significant improvement in scores at greater than 16 scans for right upper quadrant (p = 0.0018) and 13 scans for abdominal aorta (p = 0.0018). Conclusion: Adequate resident training for interpretation for certain applications such as right upper quadrant and abdominal aorta, may be achievable using smaller numbers than the generally accepted guideline of 25 scans per application. Additionally, the number of scans needed to reach competency may be variable dependent on the specific ultrasound application.

Focused Assessment Sonography for Trauma (FAST) training: a systematic review

BACKGROUND

The aim of this study was to systematically review the different methods for training Focused Assessment Sonography for Trauma (FAST), course design, and requirements for hospital credentialing.

METHODS

We searched MEDLINE/PubMed, EMBASE, and the Cochrane database and performed a manual search of selected papers. All papers and abstracts written in English that studied training and education of FAST were included. Papers were critically evaluated, looking into training methods and models of FAST, their advantages and disadvantages, number and type of training hours, practice exams in the course, and number of cases advised to achieve hospital credentialing.

RESULTS

A total of 52 studies were critically analyzed. The theoretical part of the courses lasted over a median (range) of 4 (1-16) h (n = 35 studies), while the practical part lasted over a median (range) of 4 (1-32) h (n = 34 studies). The participants performed a median (range) of 10 (3-20) FAST exams during the courses (n = 13 studies). The most commonly used model was the normal human model (65 %), followed by peritoneal dialysis patients (27 %). The least used models were animal (4 %) and cadaveric models (2 %). Each of these models had their advantages and disadvantages. The median number (range) of FAST exams needed for credentialing was 50 (10-200) (n = 19 studies).

CONCLUSION

Standardization of FAST training is important to improving the clinical impact of FAST. Different models used in FAST training are complementary; each has its own advantages and disadvantages. It is recommended that FAST courses be at least 2 days (16 h) long. The first day should include 4 h of theory and 4 h of training on normal human models. The second day should enforce learning using animal models, case scenarios including video clips, or simulators.

Bedside ultrasonographic diagnosis of pneumothorax

Pneumothorax (PTX) is the presence of an excessive amount of air between the two layers of the pleura. The clinical results depend on the extent of lung collapse. Bedside lung ultrasonography (BLUS) is a valuable way to diagnose PTX in the emergency department. The lung point is a pathognomonic sign of PTX. Here, we present a previously healthy 17-year-old male with left shoulder pain for 2 days, who was referred to the emergency department (ED). He had no history of trauma. BLUS was performed by the emergency physician. The lung point was detected with BLUS, and he was diagnosed with primary spontaneous PTX. Needle aspiration was performed. The patient was followed up with BLUS. Evidence of PTX was absent in BLUS after 6 h, and the patient was discharged for follow-up by a respiratory physician. In this case, the lung point in BLUS helped us make an accurate diagnosis of primary spontaneous PTX and invasive management of disease was arranged accordingly.

Three-year emergency medicine training program in The Netherlands: first evaluation from the residents' perspective

BACKGROUND

The Netherlands' 3-year training in Emergency Medicine (EM) was formally approved and introduced in November 2008. To identify areas for improvement, we conducted the first evaluation of this curriculum from the residents' perspective.

METHODS

A questionnaire was composed on ten aspects of the curriculum. It contained multiple-choice, open and opinion questions; answers to the latter were classified using the Likert scale. The questionnaires were mailed to all enrolled residents.

RESULTS

We mailed questionnaires to all 189 enrolled residents, and 105 responded (55.6%). Although they were satisfied with their training overall, 96.2% thought it was currently too short: 18.3% desired extension to 4 years, 76.0% to 5 and 1.9% to 6 years. Nevertheless, residents expected that they would function effectively as emergency physicians (EPs) after finishing their 3-year training program. Bedside teaching was assessed positively by 35.2%. All rotations were assessed positively, with the general practice rotation seen as contributing the least to the program. According to 43.7%, supervising EPs were available for consultation; 40.7% thought that, in a clinical capacity, the EP was sufficiently present during residents' shifts. When EPs were present, 82.5% found them to be easily accessible, and 66.6% viewed them as role models. In the Emergency Medicine Departments (EDs) with a higher number of EPs employed, residents tended to perceive better supervision and were more likely to see their EPs as role models. While residents were stimulated to do research, actual support and assistance needed to be improved.

CONCLUSION

Although overall, the current training program was evaluated positively, the residents identified four areas for improvement: (1) in training hospitals, trained EPs should be present more continuously for clinical supervision; (2) bedside teaching should be improved, (3) scientific research should be facilitated more and (4) the training program should be extended.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography

OBJECTIVES

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS).

METHODS

This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS.

RESULTS

Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively).

CONCLUSIONS

Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

False-negative FAST examination: associations with injury characteristics and patient outcomes

STUDY OBJECTIVE

Focused assessment with sonography in trauma (FAST) is widely used for evaluating patients with blunt abdominal trauma; however, it sometimes produces false-negative results. Presenting characteristics in the emergency department may help identify patients at risk for false-negative FAST result or help the physician predict injuries in patients with a negative FAST result who are unstable or deteriorate during observation. Alternatively, false-negative FAST may have no clinical significance. The objectives of this study are to estimate associations between false-negative FAST results and patient characteristics, specific abdominal organ injuries, and patient outcomes.

METHODS

This was a retrospective cohort study including consecutive patients who presented to an urban Level I trauma center between July 2005 and December 2008 with blunt abdominal trauma, a documented FAST, and pathologic free fluid as determined by computed tomography, diagnostic peritoneal lavage, laparotomy, or autopsy. Physicians blinded to the study purpose used standardized abstraction methods to confirm FAST results and the presence of pathologic free fluid. Multivariable modeling was used to assess associations between potential predictors of a false-negative FAST result and false-negative FAST result and adverse outcomes.

RESULTS

During the study period, 332 patients met inclusion criteria. Median age was 32 years (interquartile range 23 to 45 years), 67% were male patients, the median Injury Severity Score was 27 (interquartile range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury was positively associated with false-negative FAST result (odds ratio [OR] 4.9; 95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR 0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with false-negative FAST result. False-negative FAST result was not associated with mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST results were substantially less likely to require therapeutic laparotomy (OR 0.31; 95% CI 0.19 to 0.52).

CONCLUSION

Patients with severe head injuries and minor abdominal injuries were more likely to have a false-negative than true-positive FAST result. On the other hand, patients with spleen, liver, or abdominal vascular injuries are less likely to have false-negative FAST examination results. Adverse outcomes were not associated with false-negative FAST examination results, and in fact patients with false-negative FAST result were less likely to have a therapeutic laparotomy. Further studies are needed to assess the strength of these findings.

Assessment of a training curriculum for emergency ultrasound for pediatric soft tissue infections

OBJECTIVES

The objective was to evaluate a training protocol for pediatric emergency physicians (EPs) learning emergency ultrasound (EUS) for the evaluation of skin and soft tissue infections (SSTIs) by assessing technical ability and interrater reliability.

METHODS

Pediatric emergency medicine (EM) fellows and attending physicians completed a 1-day training course taught by an expert emergency sonologist. After the course, EPs performed proctored examinations on patients with SSTIs until they reached predefined performance criteria, after which they performed independent EUS examinations. All EUS examinations were recorded using still images and video clips that were reviewed and rated by the expert sonologist on four technical measures and combined into a composite score. The expert's opinion regarding the presence or absence of an abscess was also compared to the study sonologist's opinion and analyzed for interrater reliability.

RESULTS

Seven EPs performed 107 EUS examinations. The mean (±SD) composite score for the evaluation of technical ability for the first EUS was 3.3 ± 0.14 (on a 4-point scale), indicating a high level of quality following the training course. There was a small amount of improvement in the quality score (0.015, 95% confidence interval [CI] = 0.0003 to 0.03) with each consecutive EUS examination. The interrater reliability between the sonologist and the expert for the presence of an abscess as measured by the kappa statistic was 0.80 (95% CI = 0.63 to 0.97), indicating substantial agreement.

CONCLUSIONS

After a brief training program, pediatric EPs can perform technically successful emergency EUS examination of SSTIs, with excellent agreement with an expert sonologist.

An Evidence-Based Approach for Integrating Bedside Ultrasound Into Routine Practice in the Assessment of Undifferentiated Shock

Undifferentiated hypotension remains a central diagnostic and therapeutic challenge in emergency and critical care medicine. Increasingly, bedside ultrasound conducted by intensivists and emergency medicine providers is assuming a central role in diagnosis and resuscitation of hypotension. This review discusses sample algorithms for the bedside ultrasonographic assessment of undifferentiated shock and outlines an evidence-based framework for the intensivist seeking to incorporate bedside ultrasound into daily clinical practice. The literature regarding specific applications including cardiac, thoracic, pulmonary, and vascular assessment is briefly reviewed, as is the evidence pertaining to effective implementation, training, credentialing, and ongoing quality assurance.

Ultrasound in trauma

Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. In regional trauma, ultrasound can be used to detect fractures, many vascular injuries, musculoskeletal injuries, testicular injuries and can assess foetal viability in pregnant trauma patients. Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time, allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.