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Park CH, Yoon H, Jo IJ, Woo S, Heo S, Chang H, Lee G, Park JE, Kim T, Lee SU, Hwang SY, Cha WC, Shin TG. A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View. Diagnostics (Basel) 2023; 13:2412. [PMID: 37510155 PMCID: PMC10378499 DOI: 10.3390/diagnostics13142412] [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: 05/19/2023] [Revised: 06/17/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.
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Affiliation(s)
- Chan-Ho Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Ik-Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Sookyoung Woo
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center; Seoul 06351, Republic of Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Guntak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Jong-Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Se-Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Sung-Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Won-Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
| | - Tae-Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Republic of Korea
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Evaluation of diagnostic efficiency of bedside cardiac ultrasonography performed by emergency specialist. Ir J Med Sci 2022:10.1007/s11845-022-03128-1. [PMID: 35962251 DOI: 10.1007/s11845-022-03128-1] [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: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND In emergency medicine, ultrasound is frequently used in the diagnostic and therapeutic procedures and evaluation of treatment of critically ill patients simultaneously, due to its bedside applicability, rapidness and inexpensive cost. AIM The competence of emergency physician in focused cardiac ultrasound evaluations and the success of diagnosing cardiac diseases were evaluated in a patient group presenting to the emergency department with complaints of non-traumatic chest pain and shortness of breath. METHODS We included patients with complaints of chest pain and shortness of breath and underwent cardiac ultrasound performed by emergency physician. Then, patients were evaluated by a cardiologist. The diagnoses made by the emergency physician were compared with the diagnoses made by the cardiologist. RESULTS A total of 303 patients were included. The diagnoses made by the emergency medicine specialist and cardiologist as a result of the evaluation were recorded as 56.7% vs 52.10% for acute coronary syndrome, 29.70% vs 31.60% for congestive heart failure, 3.6% vs 3.30% for pulmonary embolism, 2.1% vs 2.10% for hypertensive pulmonary edema, 1.9% vs 2.10% for pericarditis, and 0.60% vs 1.30% for aortic dissection. CONCLUSION It was determined that focused cardiac ultrasound performed by emergency physician was sufficient in terms of accuracy of findings and diagnosis, and played an important role in excluding or including fatal diagnoses and conditions. The success rates of emergency physician can be further increased with long-term and comprehensive training programs.
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Dadon Z, Butnaru A, Rosenmann D, Alper‐Suissa L, Glikson M, Alpert EA. Use of artificial intelligence as a didactic tool to improve ejection fraction assessment in the emergency department: A randomized controlled pilot study. AEM EDUCATION AND TRAINING 2022; 6:e10738. [PMID: 35493288 PMCID: PMC9045570 DOI: 10.1002/aet2.10738] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Incorporating artificial intelligence (AI) into echocardiography operated by clinicians working in the emergency department to accurately assess left-ventricular ejection fraction (LVEF) may lead to better diagnostic decisions. This randomized controlled pilot study aimed to evaluate AI use as a didactic tool to improve noncardiologist clinicians' assessment of LVEF from the apical 4-chamber (A4ch) view. METHODS This prospective randomized controlled pilot study tested the feasibility and acceptability of the incorporation of AI as a didactic tool by comparing the ability of 16 clinicians who work in the emergency department to assess LVEF before and after the introduction of an AI-based ultrasound application. Following a brief didactic course, participants were randomly equally divided into an intervention and a control group. In each of the first and second sessions, both groups were shown 10 echocardiography A4ch clips and asked to assess LVEF. Following each clip assessment, only the intervention group was shown the results of the AI-based tool. For the final session, both groups were presented with a new set of 40 clips and asked to evaluate the LVEF. RESULTS In the "normal-abnormal" category evaluation, as related to own baseline accuracy assessment, the intervention group had an improvement in accuracy on 50 consecutive clip assessments compared with a decline in the control group (0.10 vs. -0.12, respectively, p = 0.038). In the "significantly reduced LVEF" category, the intervention group showed significantly less decline in clip assessment as compared to the control group (-0.03 vs. -0.12, respectively, p = 0.050). CONCLUSIONS A study involving AI incorporation as a didactic tool for clinicians working in the emergency department appears feasible and acceptable. The introduction of an AI-based tool to clinicians working in the emergency department improved the assessment accuracy of LVEF as compared to the control group.
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Affiliation(s)
- Ziv Dadon
- Jesselson Integrated Heart CenterShaare Zedek Medical CenterJerusalemIsrael
| | - Adi Butnaru
- Jesselson Integrated Heart CenterShaare Zedek Medical CenterJerusalemIsrael
| | - David Rosenmann
- Jesselson Integrated Heart CenterShaare Zedek Medical CenterJerusalemIsrael
| | - Liat Alper‐Suissa
- Jesselson Integrated Heart CenterShaare Zedek Medical CenterJerusalemIsrael
| | - Michael Glikson
- Jesselson Integrated Heart CenterShaare Zedek Medical CenterThe Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Evan A. Alpert
- Department of Emergency Medicine, Shaare Zedek Medical CenterThe Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
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Dadon Z, Levi N, Orlev A, Belman D, Alpert EA, Glikson M, Gottlieb S, Butnaru A. The Utility of Handheld Cardiac and Lung Ultrasound in Predicting Outcomes of Hospitalised Patients With COVID-19. Can J Cardiol 2022; 38:338-346. [PMID: 34871728 PMCID: PMC8641404 DOI: 10.1016/j.cjca.2021.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/14/2021] [Accepted: 11/28/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Strict isolation precautions limit formal echocardiography use in the setting of COVID-19 infection. Information on the importance of handheld focused ultrasound for cardiac evaluation in these patients is scarce. This study investigated the utility of a handheld echocardiography device in hospitalised patients with COVID-19 in diagnosing cardiac pathologies and predicting the composite end point of in-hospital death, mechanical ventilation, shock, and acute decompensated heart failure. METHODS From April 28 through July 27, 2020, consecutive patients diagnosed with COVID-19 underwent evaluation with the use of handheld ultrasound (Vscan Extend with Dual Probe; GE Healthcare) within 48 hours of admission. The patients were divided into 2 groups: "normal" and "abnormal" echocardiogram, as defined by biventricular systolic dysfunction/enlargement or moderate/severe valvular regurgitation/stenosis. RESULTS Among 102 patients, 26 (25.5%) had abnormal echocardiograms. They were older with more comorbidities and more severe presenting symptoms compared with the group with normal echocardiograms. The prevalences of the composite outcome among low- and high-risk patients (oxygen saturation < 94%) were 3.1% and 27.1%, respectively. Multivariate logistic regression analysis revealed that an abnormal echocardiogram at presentation was independently associated with the composite end point (odds ratio 6.19, 95% confidence interval 1.50-25.57; P = 0.012). CONCLUSIONS An abnormal echocardiogram in COVID-19 infection settings is associated with a higher burden of medical comorbidities and independently predicts major adverse end points. Handheld focused echocardiography can be used as an important "rule-out" tool among high-risk patients with COVID-19 and should be integrated into their routine admission evaluation. However, its routine use among low-risk patients is not recommended.
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Affiliation(s)
- Ziv Dadon
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Nir Levi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Amir Orlev
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Daniel Belman
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Evan Avraham Alpert
- Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine Hebrew University, Jerusalem, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine Hebrew University, Jerusalem, Israel
| | - Shmuel Gottlieb
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Adi Butnaru
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
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Falsetti L, Zaccone V, Marra AM, Tarquinio N, Viticchi G, Sampaolesi M, Riccomi F, Giovenali L, Ferrini C, Moroncini G, Nitti C, Salvi A. Clinical Method Applied to Focused Ultrasound: The Case of Wells' Score and Echocardiography in the Emergency Department: A Systematic Review and a Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:766. [PMID: 34440972 PMCID: PMC8400535 DOI: 10.3390/medicina57080766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: bedside cardiac ultrasound is a widely adopted method in Emergency Departments (ED) for extending physical examination and refining clinical diagnosis. However, in the setting of hemodynamically-stable pulmonary embolism, the diagnostic role of echocardiography is still the subject of debate. In light of its high specificity and low sensitivity, some authors suggest that echocardiographic signs of right ventricle overload could be used to rule-in pulmonary embolism. In this study, we aimed to clarify the diagnostic role of echocardiographic signs of right ventricle overload in the setting of hemodynamically-stable pulmonary embolism in the ED. Materials and Methods: we performed a systematic review of literature in PubMed, Web of Science and Cochrane databases, considering the echocardiographic signs for the diagnosis of pulmonary embolism in the ED. Studies considering unstable or shocked patients were excluded. Papers enrolling hemodynamically stable subjects were selected. We performed a diagnostic test accuracy meta-analysis for each sign, and then performed a critical evaluation according to pretest probability, assessed with Wells' score for pulmonary embolism. Results: 10 studies were finally included. We observed a good specificity and a low sensitivity of each echocardiographic sign of right ventricle overload. However, once stratified by the Wells' score, the post-test probability only increased among high-risk patients. Conclusions: signs of echocardiographic right ventricle overload should not be used to modify the clinical behavior in low- and intermediate- risk patients according to Wells' score classification. Among high-risk patients, however, echocardiographic signs could help a physician in detecting patients with the highest probability of pulmonary embolism, necessitating a confirmation by computed tomography with pulmonary angiography. However, a focused cardiac and thoracic ultrasound investigation is useful for the differential diagnosis of dyspnea and chest pain in the ED.
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Affiliation(s)
- Lorenzo Falsetti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy; (V.Z.); (C.N.); (A.S.)
| | - Vincenzo Zaccone
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy; (V.Z.); (C.N.); (A.S.)
| | - Alberto M. Marra
- Department of Translational Medical Sciences, “Federico II” University, 80100 Naples, Italy;
| | - Nicola Tarquinio
- Internal Medicine Department, INRCA-IRCSS Ancona, 60027 Osimo (Ancona), Italy;
| | - Giovanna Viticchi
- Clinical and Experimental Medicine Department, Neurological Clinic, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy;
| | - Mattia Sampaolesi
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy; (M.S.); (F.R.); (L.G.); (C.F.)
| | - Francesca Riccomi
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy; (M.S.); (F.R.); (L.G.); (C.F.)
| | - Laura Giovenali
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy; (M.S.); (F.R.); (L.G.); (C.F.)
| | - Consuelo Ferrini
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy; (M.S.); (F.R.); (L.G.); (C.F.)
| | - Gianluca Moroncini
- Clinical and Experimental Medicine Department, Clinica Medica, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy;
| | - Cinzia Nitti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy; (V.Z.); (C.N.); (A.S.)
| | - Aldo Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, 60100 Ancona, Italy; (V.Z.); (C.N.); (A.S.)
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Rajamani A, Shetty K, Parmar J, Huang S, Ng J, Gunawan S, Gunawan G. Longitudinal Competence Programs for Basic Point-of-Care Ultrasound in Critical Care. Chest 2020; 158:1079-1089. [DOI: 10.1016/j.chest.2020.03.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 11/28/2022] Open
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Colony MD, Edwards F, Kellogg D. Ultrasound assisted evaluation of chest pain in the emergency department. Am J Emerg Med 2017; 36:533-539. [PMID: 28967448 DOI: 10.1016/j.ajem.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/01/2017] [Accepted: 09/02/2017] [Indexed: 10/18/2022] Open
Abstract
Chest pain is a commonly encountered emergency department complaint, with a broad differential including several life-threatening possible conditions. Ultrasound-assisted evaluation can potentially be used to rapidly and accurately arrive at the correct diagnosis. We propose an organized, ultrasound assisted evaluation of the patient with chest pain using a combination of ultrasound, echocardiography and clinical parameters. Basic echo techniques which can be mastered by residents in a short time are used plus standardized clinical questions and examination. Information is kept on a checklist. We hypothesize that this will result in a quicker, more accurate evaluation of chest pain in the ED leading to timely treatment and disposition of the patient, less provider anxiety, a reduction in the number of diagnostic errors, and the removal of false assumptions from the diagnostic process.
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Affiliation(s)
- M Deborah Colony
- Emergency Medicine Residency, Arnot Ogden Medical Center, Elmira, NY, affiliated with Lake Erie College of Osteopathic Medicine, USA.
| | - Frank Edwards
- Emergency Medicine Residency, Arnot Ogden Medical Center, USA
| | - Dylan Kellogg
- Emergency Medicine Residency, Arnot Ogden Medical Center, USA
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8
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Murphy DL, Condino AE, Gittinger MJ, Vrablik ME. Right Atrial Collapse With Hepatic Hydrothorax in Advanced Liver Disease. J Med Ultrasound 2017; 25:55-57. [PMID: 30065456 PMCID: PMC6029287 DOI: 10.1016/j.jmu.2017.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/09/2017] [Indexed: 11/09/2022] Open
Abstract
Cardiac chamber collapse secondary to extrapericardial causes is rare. Focused cardiac ultrasound (FoCUS) in the emergency department can rapidly yield important clinical information and guide management in patients presenting with dyspnea, hypotension, or other cardiopulmonary complaints of uncertain etiology. We report a case of newly-diagnosed cirrhosis with massive ascites and large pleural effusions that distorted normal cardiac anatomy and venous return, in which FoCUS was essential in differentiating underlying pathology of this sick patient and guiding therapy.
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Affiliation(s)
- David L Murphy
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Anna E Condino
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Matthew J Gittinger
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Michael E Vrablik
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
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9
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Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review. J Trauma Acute Care Surg 2016; 80:511-8. [PMID: 26670112 DOI: 10.1097/ta.0000000000000941] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.
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10
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Limb C, Siddiqui MA. Apparent asystole: are we missing a lifesaving opportunity? BMJ Case Rep 2015; 2015:bcr-2014-208364. [PMID: 25777487 DOI: 10.1136/bcr-2014-208364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The use of ultrasonography is rapidly expanding in emergency medicine. Real-time assessment offers clues to prompt diagnosis and creates opportunities for speedy intervention. We present a case of 'cardiac monitor asystole' that proved to be ventricular fibrillation on ultrasound examination. Uniquely this case demonstrates that this, typically unrecognised, form of ventricular fibrillation responds to desynchronised defibrillation, with restoration of perfusion for approximately 30 min. With increasing access to ultrasound we believe that further research is indicated to determine whether some cases of apparent asystole may best be treated by defibrillation, presenting an opportunity to save more lives than current protocols achieve.
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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Migneault D, Levine Z, de Champlain F. An unusual presentation of a massive pulmonary embolism with misleading investigation results treated with tenecteplase. Case Rep Emerg Med 2015; 2015:868519. [PMID: 25789181 PMCID: PMC4350959 DOI: 10.1155/2015/868519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/10/2015] [Indexed: 11/18/2022] Open
Abstract
Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE. Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature. Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK). Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted.
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Affiliation(s)
- David Migneault
- Department of Emergency Medicine, Vancouver General Hospital, University of British Columbia, Room 3300 910, West 10th Avenue, Vancouver, BC, Canada V5Z 1M9
| | - Zachary Levine
- Emergency Department, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room B2.117, Montreal, QC, Canada H3G 1A4
| | - François de Champlain
- Emergency Department, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room B2.117, Montreal, QC, Canada H3G 1A4
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13
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Kenny JF, Zhong X, Brown C, Das D, Royall B, Kapoor M. Bedside echocardiography for undifferentiated hypotension: diagnosis of a right heart thrombus. West J Emerg Med 2014; 16:178-80. [PMID: 25671037 PMCID: PMC4307712 DOI: 10.5811/westjem.2014.12.23262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/07/2014] [Accepted: 12/02/2014] [Indexed: 11/17/2022] Open
Abstract
A free-floating right heart thrombus is often a harbinger of a massive pulmonary embolism and must be diagnosed and treated rapidly in order to avoid significant adverse sequelae. We present the case of an 84-year-old female who presented with two days of dyspnea and was hypotensive on arrival. Bedside ultrasound was performed by the emergency physician and showed a large, mobile right heart thrombus leading to immediate administration of a thrombolytic. In this case, bedside ultrasound was utilized to help further delineate clinical care in a progressively worsening patient, leading to a potentially lifesaving treatment.
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Affiliation(s)
- James F Kenny
- Northwestern University, Emergency Medicine Residency, Chicago, Illinois
| | - Xun Zhong
- Staten Island University Hospital, Department of Emergency Medicine, Staten Island, New York
| | - Cara Brown
- Staten Island University Hospital, Department of Emergency Medicine, Staten Island, New York
| | - Devjani Das
- Staten Island University Hospital, Department of Emergency Medicine, Staten Island, New York
| | - Brock Royall
- Staten Island University Hospital, Department of Emergency Medicine, Staten Island, New York
| | - Monica Kapoor
- Staten Island University Hospital, Department of Emergency Medicine, Staten Island, New York
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Oviedo-García A, Algaba-Montes M, Lopez-Libano J, Alvarez-Franco JM, Diaz-Rodriguez N, Rodriguez-Lorenzo A, Grau AS. Echocardiographic windows in emergency departaments. Crit Ultrasound J 2014. [PMCID: PMC4101439 DOI: 10.1186/2036-7902-6-s1-a10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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15
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Zhang S, Zhu D, Wan Z, Cao Y. Utility of point-of-care echocardiogram in the rapid diagnosis of hypertrophic cardiomyopathy. Am J Emerg Med 2013; 31:1280-2. [PMID: 23759682 DOI: 10.1016/j.ajem.2013.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 04/27/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022] Open
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16
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Jenkins JA, Gharahbaghian L, Doniger SJ, Bradley S, Crandall S, Spain DA, Williams SR. Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. West J Emerg Med 2012; 13:305-11. [PMID: 22942927 PMCID: PMC3421967 DOI: 10.5811/westjem.2011.10.6680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 06/22/2011] [Accepted: 10/03/2011] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. METHODS This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement. RESULTS Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. CONCLUSION Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.
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Torres-Macho J, Antón-Santos JM, García-Gutierrez I, de Castro-García M, Gámez-Díez S, de la Torre PG, Latorre-Barcenilla G, Majo-Carbajo Y, Reparaz-González JC, de Casasola GG. Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period. Am J Emerg Med 2012; 30:1943-9. [PMID: 22795427 DOI: 10.1016/j.ajem.2012.04.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 02/06/2023] Open
Abstract
PURPOSES Emergency physician-performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician-performed ultrasonography for multiple categories of ultrasound use after a short training period. BASIC PROCEDURES This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation. MAIN FINDINGS A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained. PRINCIPAL CONCLUSIONS Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.
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Affiliation(s)
- Juan Torres-Macho
- Emergency Department, Hospital Infanta Cristina, Parla, Madrid, Spain.
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18
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Ecocardiografía clínica en Medicina Interna. Med Clin (Barc) 2012; 138:567-9. [DOI: 10.1016/j.medcli.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 12/15/2011] [Indexed: 02/06/2023]
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Tomruk O, Erdur B, Cetin G, Ergin A, Avcil M, Kapci M. Assessment of Cardiac Ultrasonography in Predicting Outcome in Adult Cardiac Arrest. J Int Med Res 2012; 40:804-9. [DOI: 10.1177/147323001204000247] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE: A prospective follow-up study to evaluate the ability of cardiac ultrasonography performed by emergency physicians to predict resuscitation outcome in adult cardiac arrest patients. METHODS: Ultrasonographic examination of the subxiphoid cardiac area was made immediately on presentation to the emergency department with pulseless cardiac arrest. Sonographic cardiac activity was defined as any detected motion within the heart including the atria, ventricles or valves. Successful resuscitation was defined as any of: return of spontaneous circulation for ≥ 20 min; return of breathing; palpable pulse; measurable blood pressure. RESULTS: The study enrolled 149 patients over an 18-month period. The presence of sonographic cardiac activity at the beginning of resuscitation was significantly associated with a successful outcome (19/27 [70.4%] versus 55/122 [45.1%] patients without cardiac activity at the beginning of resuscitation). CONCLUSIONS: Ultrasonographic detection of cardiac activity may be useful in determining prognosis during cardiac arrest. Further studies are needed to elucidate the predictive value of ultrasonography in cardiac arrest patients.
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Affiliation(s)
- O Tomruk
- Department of Emergency Medicine, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - B Erdur
- Department of Emergency Medicine, Pamukkale University, Denizli, Turkey
| | - G Cetin
- Department of Emergency Medicine, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - A Ergin
- Department of Public Health, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - M Avcil
- Department of Emergency Medicine, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - M Kapci
- Department of Emergency Medicine, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
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Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.cult.2011.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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21
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Pourmand A, Boniface K. Incidental identification of right atrial mass using bedside ultrasound: cardiac angiosarcoma. West J Emerg Med 2012; 12:478-80. [PMID: 22224142 PMCID: PMC3236153 DOI: 10.5811/westjem.2011.4.1906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Revised: 09/13/2010] [Accepted: 04/11/2011] [Indexed: 11/30/2022] Open
Abstract
Background Emergency ultrasound is now used in both community and academic hospitals for rapid diagnosis and treatment of life-threatening conditions. Bedside emergency echocardiography can rapidly identify significant pathology such as pericardial effusions and tamponade, right ventricle dilatation due to pulmonary embolism, and cardiac hypokinesis, and aid in the diagnosis and management of patients in emergency department (ED). Case Report A 41-year-old man presented twice to the ED with history of abdominal pain and was diagnosed with primary cardiac angiosarcoma with point-of-care ultrasound. Conclusion This case is illustrative of how bedside cardiac ultrasound in the ED can dramatically change a patient's hospital course.
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Affiliation(s)
- Ali Pourmand
- George Washington University, Department of Emergency Medicine, Washington, DC
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22
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Emergency ultrasound diagnosis of a left atrial thrombus and diffuse emboli. Crit Ultrasound J 2011. [DOI: 10.1007/s13089-011-0073-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Abstract
Introduction
A 71-year-old female with a history of atrial fibrillation presented to the emergency department (ED) for abdominal pain. A computed tomography (CT) scan in ED showed an abdominal aortic thrombus and diffuse emboli suspicious for a cardiac source.
Methods
A bedside ultrasound was performed which confirmed the presence of a dilated left atrium with thrombus. The patient was admitted to the hospital and eventually placed on anticoagulation.
Conclusions
Atrial fibrillation is a common cause of atrial thrombus. Intracardiac thrombus can be diagnosed by bedside echocardiography in the ED. Emboli can occur as a complication of thrombus in the atrium. Management may include anticoagulation or surgical intervention.
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Cheng AB, Levine DA, Tsung JW, Phoon CKL. Emergency physician diagnosis of pediatric infective endocarditis by point-of-care echocardiography. Am J Emerg Med 2011; 30:386.e1-3. [PMID: 21266297 DOI: 10.1016/j.ajem.2010.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 12/09/2010] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alfred B Cheng
- Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York, NY 10016, USA
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Abstract
Functional echocardiography (fECHO) is the bedside use of ultrasound to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intra and extracardiac shunts. This review will focus on fECHO as a tool for the clinician to assess the hemodynamic condition of sick neonates and describe situations where fECHO can help determine a pathophysiological choice for cardiovascular support. The very low birth weight infant with hypotension during the first 24h of life, assessment and monitoring of the ductus arteriosus, assessment and response to treatment of infants with pulmonary hypertension, the infant with perinatal asphyxia and the infant with sepsis and cardiovascular compromise are reviewed. Close cooperation with pediatric cardiology, proper logistics and training programs are mandatory to achieve a 24h a day fECHO service run by bedside clinicians.
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