Accuracy of emergency physician–performed ultrasonography in the diagnosis of deep-vein thrombosis

Deep venous thrombosis (DVT) diagnostics: gleaning insights from point-of-care ultrasound (PoCUS) techniques in emergencies: a systematic review and meta-analysis

BACKGROUND

The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The "gold standard test" for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department.

AIMS

This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department.

METHODS

A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificity of POCUS protocols for DVT diagnosis compared to reference standard test was calculated.

RESULTS

Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58-97.06), 96.86% (95% CI: 95.09-98.64), 88.41% (95% CI: 82.24-94.58) and 97.25% (95% CI: 95.51-98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24-95.07), 92.71% (95% CI: 89.59-95.83), 81.27% (95% CI: 73.79-88.75), and 95.47% (95% CI: 92.93-98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21-100) and 97.05% (95% CI: 92.25-100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists.

CONCLUSION

The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.

Emergency medicine residents' learning curve in diagnosing deep vein thrombosis with 3-point venous point-of-care ultrasound

BACKGROUND

Many cases of deep vein thrombosis (DVT) are diagnosed in the emergency department, and abbreviated lower extremity venous point-of-care ultrasound (POCUS) has already shown an accuracy comparable to that of specialists. This study aimed to identify the learning curve necessary for emergency medicine (EM) residents to achieve expertise-level accuracy in diagnosing DVT through a 3-point lower extremity venous POCUS.

METHODS

This prospective study was conducted at an emergency department between May 2021 and October 2022. Four EM residents underwent a one-hour POCUS training session and performed DVT assessments in participants with DVT symptoms or confirmed pulmonary embolism. POCUS was performed at three proximal lower extremity sites to evaluate the thrombi presence and vein compressibility, with results validated by specialized radiology ultrasound. Cumulative sum (CUSUM) and the Bush and Mosteller models were used to analyze the learning curve, while generalized estimating equations were used to identify factors affecting diagnostic accuracy.

RESULTS

91 POCUS scans were conducted in 49 patients, resulting in 22% DVT confirmed by specialized venous ultrasound. In the CUSUM analysis, all four EM residents attained a 90% success rate at the common femoral vein, whereas only half achieved this rate when all three sites were considered. According to Bush and Mosteller models, 13-18 cases are required to attain 90-95% diagnostic accuracy. After 10-16 cases, the examination time for each resident decreased, and a 20% increase in examiner confidence was linked to a 2.506-fold increase in the DVT diagnosis accuracy.

CONCLUSION

EM residents generally required 13-18 cases for 90-95% DVT diagnostic accuracy, but proficiency varied among individuals, particularly requiring more cases for regions outside the common femoral vein.

Perception, Knowledge, Indications, and Future Prospects of Point-of-Care Ultrasound Among Medical Students in Saudi Arabia

Introduction Point-of-care ultrasound (POCUS) has become integral across medical specialties globally, addressing clinical queries, guiding procedures, and bridging the gap between physical examination and advanced imaging. Early ultrasound training for medical students enhances clinical decision-making and reduces diagnostic errors. Aims To evaluate the knowledge and attitude of senior medical students towards POCUS and to assess knowledge gaps and difficulties encountered by senior medical students to assist in the development of future curricula. Methodology This is an observational, cross-sectional approach to evaluate knowledge, attitude, and practice of POCUS among senior medical students in the Kingdom of Saudi Arabia. The study was conducted from January to September 2023. An electronic questionnaire was distributed through online platforms utilizing medical school databases across various regions. The survey encompassed sociodemographics, training methods, diagnostic indications, and participants' self-reported proficiency and attitudes toward POCUS. The data was chiefly collected using the Likert scale. Descriptive statistics were used to describe the quantitative and categorical variables. Bivariate and multivariate analyses were used to examine correlations. Results A total of 359 senior medical students completed the survey. Most responders were females (57.9%) with the predominating age group being ≤ 24 years (83.6%). The students predominantly were from the Central region of Saudi Arabia (75.5%). Ultrasound training varied among responders; 31.5% received formal courses (median duration: two hours) and 23.4% informal courses (median duration: four hours). Around 17.3% practiced POCUS self-teaching (median duration: four hours). A total of 3.6% had formal POCUS accreditation. A gargantuan 82.2% never used POCUS in their attached hospital for a variety of reasons. Multivariable logistic binary regression analysis showed a positive correlation between students' self-teaching of POCUS and their perceived difficulty performing an ultrasound examination for patients in daily practice. Discussion A comparable study was done at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) in 2022 surveying 229 senior medical students by Rajendram et al. In their study, 21.4% completed formal courses and 12.7% took informal courses. While many students in our study were not exposed to POCUS (82.2%), KSAU-HS reported a higher percentage reaching 94.8%. A study by Russel et al. demonstrated more than half of 154 surveyed medical schools in the United States have implemented POCUS into their students' curriculum. Conclusion POCUS stands as a valuable skill that can enhance the educational journey of undergraduate medical students. Considering that a significant number of participants haven't yet taken formal medical school courses suggests a lack of awareness about its significance in the medical field. Offering additional courses with practical components could enhance the proficiency, confidence, and outlook of medical students toward POCUS.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

Systematic review of the use of ultrasound for venous assessment and venous thrombosis screening in spaceflight

The validity of venous ultrasound (V-US) for the diagnosis of deep vein thrombosis (DVT) during spaceflight is unknown and difficult to establish in diagnostic accuracy and diagnostic management studies in this context. We performed a systematic review of the use of V-US in the upper-body venous system in spaceflight to identify microgravity-related changes and the effect of venous interventions to reverse them, and to assess appropriateness of spaceflight V-US with terrestrial standards. An appropriateness tool was developed following expert panel discussions and review of terrestrial diagnostic studies, including criteria relevant to crew experience, in-flight equipment, assessment sites, ultrasound modalities, and DVT diagnosis. Microgravity-related findings reported as an increase in internal jugular vein (IJV) cross-sectional area and pressure were associated with reduced, stagnant, and retrograde flow. Changes were on average responsive to venous interventions using lower body negative pressure, Bracelets, Valsalva and Mueller manoeuvres, and contralateral IJV compression. In comparison with terrestrial standards, spaceflight V-US did not meet all appropriateness criteria. In DVT studies (n = 3), a single thrombosis was reported and only ultrasound modality criterion met the standards. In the other studies (n = 15), all the criteria were appropriate except crew experience criterion, which was appropriate in only four studies. Future practice and research should account for microgravity-related changes, evaluate individual effect of venous interventions, and adopt Earth-based V-US standards.

Remote Expert DVT Triaging of Novice-User Compression Sonography with AI-Guidance

BACKGROUND

Compression ultrasonography of the leg is established for triaging proximal lower extremity deep vein thrombosis (DVT). AutoDVT, a machine-learning software, provides a tool for nonspecialists in acquiring compression sequences to be reviewed by an expert for patient triage. The purpose of this study was to test image acquisition and remote triaging in a clinical setting.

METHODS

Patients with a suspected DVT were recruited at 2 centers in Germany and Greece. Enrolled patients underwent an artificial intelligence-guided two-point compression examination by a nonspecialist using a handheld ultrasound device prior to a standard scan. Images collected by the software were uploaded for blind review by 5 qualified physicians. All reviewers rated the quality of all sequences on the American College of Emergency Physicians (ACEP) image quality scale (score 1-5, ≥ 3 defined as adequate imaging quality) and for an ACEP score ≥3, chose "Compressible", "Incompressible", or "Other". Sensitivity and specificity were calculated for adequate quality scans with an assessment as "Compressible" or "Incompressible". We define this group as diagnostic quality. To simulate a triaging clinical algorithm, a post hoc analysis was performed merging the "incomplete", the "low quality", and the "Incompressible" into a high-risk group for proximal DVT.

RESULTS

Seventy-three patients (average age 64.2 years, 44% females) were eligible for inclusion and scanned by 3 nonultrasound-qualified healthcare professionals. Three patients were excluded from further analysis due to incomplete scans. Sixty two of 70 (88.57%) of the completed scans were judged to be of adequate image quality with an average ACEP score of 3.35. Forty seven of 62 adequate AutoDVT scans were assessed as diagnostic quality, of which 8 were interpreted as positive for proximal DVT by the reviewers resulting in a sensitivity of 100% and specificity of 95.12%. When simulating a triaging algorithm, 34/73 (46.58%) of patients would be triaged as high risk and 8 would be confirmed as positive for proximal DVT (6 in the diagnostic and 2 in the low-quality cohort). Of 39/73 patients triaged as low risk, all were negative for proximal DVT in standard duplex; thus, this triaging algorithm could potentially save 53.42% of standard duplex scans.

CONCLUSIONS

Machine learning software was able to aid nonexperts in acquiring valid ultrasound images of venous compressions and allowed remote triaging. This strategy allows faster diagnosis and treatment of high-risk patients and can spare the need for multiple unnecessary duplex scans, the vast majority being negative.

Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis

Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.

Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit

The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.

Impact of Didactic Instruction on the Utilization of Point-of-Care Ultrasound in Family Medicine Residents

Background and Objectives In 2014, the Council of Academic Family Medicine released recommendations for the education of family medicine residents in point-of-care ultrasound (POCUS) curricula for Family Medicine Residency programs. One barrier to resident education in POCUS is the lack of access to equipment. This pilot study evaluates whether introducing didactic education on POCUS within a Family Medicine Residency program, with limited access to equipment, correlated with increased utilization of ultrasound by residents. Methods Sixteen family medicine residents participated in the intervention, consisting of a four-hour didactic ultrasound session. Resident confidence in POCUS was evaluated utilizing a Likert scale. Resident utilization of POCUS in a clinical setting was also evaluated by review and analysis of resident procedure logs in the New Innovations database. Results The resident confidence in all skills increased immediately after the completion of the didactic teaching session. Residents demonstrated improved confidence in needle guidance immediately and six weeks after the session (p < 0.001). A review of resident activity two years after the intervention revealed a 9.6% increase in the proportion of resident ultrasounds performed compared to the academic year before the intervention. Conclusions Access to equipment is an ongoing barrier to Family Medicine Residency programs in providing education on POCUS. The results of this study indicate that introducing the basics of POCUS via a didactic teaching session not only increased resident confidence in basic ultrasound but also correlated with increased utilization of POCUS. This increased utilization occurred despite residents not having access to ultrasound in their home clinics.

Risk factors and prediction model of nomogram for preoperative calf muscle vein thrombosis in geriatric hip fracture patients

Introduction

Calf muscular vein thrombosis (CMVT) is a common complication in geriatric hip fracture patients. Despite its high incidence, prior research on the topic is limited. The occurrence of CMVT in patients will prolong the preoperative waiting time and even lead to serious thromboembolic events, which can be detrimental to the patient's prognosis. Therefore, this study aimed to identify the risk factors for preoperative CMVT in geriatric hip fracture patients and construct a nomogram model to predict the risk of preoperative CMVT in patients.

Materials and methods

Geriatric hip fracture patients who underwent surgery between January 2019 and January 2022 were included. The patients were categorized into two groups depending on whether they had preoperative CMVT, confirmed through Color Doppler ultrasound or venography examination. Univariate and multivariate logistic regression analyses were used to analyze demographic characteristics, medical history, comorbidities, and laboratory tests. A nomogram was constructed to predict preoperative CMVT in geriatric hip fracture patients based on the results of the multivariate logistic regression.

Results

Three hundred and eighty-eight geriatric hip fracture patients, including one hundred and thirty-four patients with CMVT and two hundred and fifty-four patients without CMVT, were ultimately included in our study. After multivariable logistic regression analysis, the time from injury to admission, smoking history, serum albumin levels, and D-dimer levels was identified as independent risk factors and was entered into a nomogram model. The nomogram showed robust discrimination, with an area under the receiver operating characteristic curve of 0.805. The calibration curve showed strong agreement between the CMVT probabilities predicted by the nomogram and the actual probabilities. The decision curve analysis illustrates the excellent clinical utility of the model.

Conclusion

We have constructed a new nomogram prediction model that can effectively predict the risk of preoperative CMVT in geriatric hip fracture patients based on their medical history and blood test results. This model can help clinicians make individualized predictions of CMVT that are tailored to each patient's unique circumstances.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

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

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

Acute Upper Extremity Arterial Occlusion Diagnosed on POCUS in the Emergency Department

Upper extremity acute limb ischemia (ALI) is a limb-threatening and potentially lethal pathology that is most commonly caused by vascular embolization. Outcomes of limb ischemia are time-sensitive due to the correlation between a longer time from symptom onset to intervention with a vastly higher risk of amputation. In this report, point of care ultrasound (POCUS) was utilized to rapidly diagnose a patient with a proximal right brachial artery embolic occlusion, prompting expedited surgical consultation and successful embolectomy. POCUS can provide a focused vascular examination of the limbs to expedite diagnosis of time-sensitive ALI and facilitate timely medical intervention and surgical consultation.

Point‑of‑Care Ultrasound - accuracy, education

A review article discussing the reliability of Point-of-Care ultrasound and education in this method in various fields of medicine.

Point-of-care ultrasound in pre-bronchoscopy assessment of acute dyspnea: A case of concurrent massive pulmonary embolism and deep vein thrombosis

Point-of-care ultrasound (POCUS) leads to efficient real-time diagnosis in a wide range of medical specialties. We describe the use of cardiac, lung and lower limb POCUS to rapidly diagnose massive pulmonary embolism and deep vein thrombosis in a 64-year-old patient presenting with acute dyspnea prior to elective bronchoscopy. Left femoral vein thrombus and features of increased right heart pressure on POCUS led to the decision to administer fibrinolytic therapy, with subsequent CT pulmonary angiogram confirming bilateral PE. The use of POCUS allowed for rapid imaging and interpretation leading to a rapid diagnosis of PE, thus fast-tracking lifesaving anticoagulation, especially in an outpatient setting.

Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure

BACKGROUND

Heart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED.

METHODS

This retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration.

RESULTS

Of 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1-q3), 112 min; range, 65-163 min) compared to the non-FoCUS group (median time, 131 min; range, 71-229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04-2.55) than in the non-FoCUS group.

CONCLUSIONS

Early administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.

Venous Thromboembolism in Sepsis: From Bench to Bedside

Septic patients were commonly affected by coagulation disorders; thus, they are at high risk of thrombotic complications. In the last decades, novel knowledge has emerged about the interconnected and reciprocal influence of immune and coagulation systems. This phenomenon is called immunothrombosis, and it indicates an effective response whereby immune cells and the coagulation cascade cooperate to limit pathogen invasion and endothelial damage. When this network becomes dysregulated due to a systemic inflammatory activation, as occurs during sepsis, it can result in pathological thrombosis. Endothelium, platelets and neutrophils are the main characters involved in this process, together with the TF and coagulation cascade, playing a critical role in both the host defense and in thrombogenesis. A deeper understanding of this relationship may allow us to answer the growing need for clinical instruments to establish the thrombotic risk and treatments that consider more the connection between coagulation and inflammation. Heparin remains the principal therapeutical response to this phenomenon, although not sufficiently effective. To date, no other significant alternatives have been found yet. In this review, we discuss the role of sepsis-related inflammation in the development and resolution of venous thromboembolism and its clinical implications, from bench to bedside.

Knowledge of point-of-care ultrasound and management of deep vein thrombosis patient in resource limited setup: A case report

Introduction

and importance: Deep vein thrombosis (DVT), frequently encountered in an emergency setting, if not identified and managed early, leads to pulmonary embolism that may be life threatening to the patient. The use of point-of-care ultrasound (POCUS) can be used as an effective and time saving tool for diagnosis of such life threatening conditions.

Case presentation

We present a case of a 53 years old male who presented to the emergency department (ED) with complaints of swelling and pain in the left lower limb for one week and redness of overlying skin for the same duration. Following a point-of-care ultrasound scan, a diagnosis of DVT was made. The condition was quickly identified and promptly treated preventing possible complications.

Discussion

Use of point-of-care ultrasound to diagnose DVT has been shown to decrease the need for comprehensive scans, decrease time to diagnosis and length of stay at the emergency department. To improve medical care by increasing early detection, lowering costs, and improving overall patient care, more training of emergency physicians in ultrasound technique and standardized use of ultrasound to screen for DVT in the ED is required.

Conclusion

This case report highlights how, despite the unavailability of sophisticated diagnostic procedures, a skill of using POCUS can prove to be lifesaving in a resource-limited setting.

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Deep vein thrombosis is a life-threatening condition requiring prompt diagnosis and treatment.

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DVT, if not managed timely can lead to complications like pulmonary embolism.

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Point-of-care ultrasound (POCUS) can help detect DVT timely.

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Use of POCUS can prove valuable in resource limited setting where sophisticated tools to diagnose conditions such as DVT are unavailable.

The “Black Pattern”, a Simplified Ultrasound Approach to Non-Traumatic Abdominal Emergencies

Background: A key issue in abdominal US is the assessment of fluid, which is usually anechoic, thus appearing “black”. Our approach focuses on searching for fluid in non-traumatic patients, providing a new, simplified method for point-of-care US (POCUS). Objective: Fluid assessment is based on a three-step analysis that we can thus summarize. 1. Look for black where it should not be. This means searching for effusions or collections. 2. Check if black is too much. This means evaluating anatomical landmarks where fluid should normally be present but may be abnormally abundant. 3. Look for black that is not clearly black. This means evaluating fluid aspects, whether wholly anechoic or not (suggesting heterogeneous or corpusculated fluid). Discussion: Using this simple method focused on US fluid presence and appearance should help clinicians to make a timely diagnosis. Although our simplified, systematic algorithm of POCUS may identify abnormalities; this usually entails a second-level imaging. An accurate knowledge of the physio–pathological and anatomical ultrasound bases remains essential in applying this algorithm. Conclusion: The black pattern approach in non -traumatic emergencies may be applied to a broad spectrum of abnormalities. It may represent a valuable aid for emergency physicians, especially if inexperienced, involved in a variety of non-traumatic scenarios. It may also be a simple and effective teaching aid for US beginners.

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

Introduction

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

Case Series

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

Conclusion

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

Paget–Schroetter syndrome: An unfamiliar cause of upper-limb deep venous thrombosis

Paget−Schroetter syndrome (PSS), which is also called “effort thrombosis,” is a venous variant of thoracic outlet syndrome. We report a rare case of upper-limb deep venous thrombosis (ULDVT) in a young patient who was later diagnosed as PSS. PSS is a rare cause of ULDVT, and it is usually seen in young adults who are involved in strenuous physical activity. PSS is either due to anatomical abnormality of the thoracic outlet or due to repeated microtrauma to the endothelium of the subclavian/axillary vein. Clinically, the patient usually presents with signs and symptoms of ULDVT. Noninvasive Doppler ultrasonography is the initial investigation of choice, but computerized tomography and digital subtraction angiography are the gold standards for diagnosis. Treatment consists of therapeutic anticoagulation, catheter-directed thrombolysis, first rib resection, and postoperative oral anticoagulation. Although the PSS less likely causes pulmonary embolism, it can contribute to postthrombotic syndrome. PSS is a rare and distinct clinical entity, and most emergency care or primary care physicians are unaware of this condition. PSS requires rapid diagnosis, timely thrombolysis, and prompt referral to a vascular and thoracic surgeon.

Training medical students in physical examination and point-of-care ultrasound: An assessment of the needs and barriers to acquiring skills in point-of-care ultrasound

BACKGROUND:

With growth of the use of point of care ultrasound (PoCUS) around the world, some medical schools have incorporated this skill into their undergraduate curricula. However, because of epidemiology of disease and regional differences in approaches to patient care, global application of PoCUS might not be possible. Before creating a PoCUS teaching course, it is critical to perform a needs analysis and recognize the training obstacles.

MATERIALS AND METHODS:

A validated online questionnaire was given to final-year medical students at our institution to evaluate their perceptions of the applicability of specific clinical findings, and their own capability to detect these signs clinically and with PoCUS. The skill insufficiency was assessed by deducting the self-reported clinical and ultrasound skill level from the perceived usefulness of each clinical finding.

RESULTS:

The levels of expertise and knowledge in the 229 students who participated were not up to the expected standard. The applicability of detection of abdominal aortic aneurysm (AAA) (3.9 ± standard deviation [SD] 1.4) was the highest. However, detection of interstitial syndrome (3.0 ± SD 1.1) was perceived as the least applicable. The deficit was highest in the detection of AAA (mean 0.95 ± SD 2.4) and lowest for hepatomegaly (mean 0.57 ± SD 2.3). Although the majority agreed that training of preclinical and clinical medical students would be beneficial, 52 (22.7%) showed no interest, and 60% (n = 136) reported that they did not have the time to develop the skill.

CONCLUSION:

Although medical students in Saudi Arabia claim that PoCUS is an important skill, there are significant gaps in their skill, indicating the need for PoCUS training. However, a number of obstacles must be overcome in the process.

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel

The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."

Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial

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.

Thromboembolic Events and Role of Point of Care Ultrasound in Hospitalized Covid-19 Patients Needing Intensive Care Unit Admission

BACKGROUND

Covid-19 associated coagulopathy (CAC) is associated with prothrombotic state and thromboembolism. However, true incidence of thromboembolic events is difficult to determine in the ICU setting. The aim of our study was to investigate the cumulative incidence of thromboembolic events in Covid-19 patients needing intensive care unit (ICU) admission and assessing the utility of point of care ultrasound (POCUS) to screen for and diagnose lower extremity deep venous thrombosis (DVT).

METHODS

We conducted a prospective observational study between April 22nd and May 26th, 2020 where all adult patients with the diagnosis of Covid-19 pneumonia admitted to 8 ICUs of Montefiore Medical Center were included. POCUS exam was performed on all patients at day 1 of ICU admission and at day 7 and 14 after the first exam.

RESULTS

The primary outcome was to study the cumulative incidence of thromboembolic events in Covid-19 patients needing ICU admission. A total of 107 patients were included. All patients got POCUS exam on day 1 in the ICU, 62% got day 7 and 41% got day 14 exam. POCUS diagnosed 17 lower extremity DVTs on day 1, 3 new on day 7 and 1 new on day 14. Forty patients developed 52 thromboembolic events, with the rate of 37.3%. We found a high 45-day cumulative incidence of thromboembolic events of 37% and a high 45-day cumulative incidence of lower and upper extremity DVT of 21% and 10% respectively. Twelve (30%) patients had failure of therapeutic anticoagulation. Occurrence of a thromboembolic event was not associated with a higher risk of mortality (HR 1.08, p value = .81).

CONCLUSIONS

Covid-19 patients in ICU have a high cumulative incidence of thromboembolic events, but not associated with higher mortality. POCUS is an excellent tool to help screen and diagnose DVT during a pandemic.

Thyroid Storm-induced Takotsubo Cardiomyopathy Presenting as Acute Chest Pain: A Case Report

Introduction

Stress-induced cardiomyopathy is a rare but serious cause of chest pain, which in recent studies has been shown to carry a similar in-hospital mortality to acute ST-elevation myocardial infarction. The pathophysiology of the disease is thought to be secondary to dysregulated catecholamine effects on myocardium.

Case Report

We present a case of a previously healthy female without known thyroid disease who presented to the emergency department for acute chest pain and was found to have thyroid storm-induced cardiomyopathy in a typical stress-induced cardiomyopathy pattern without evidence of coronary disease on catheterization.

Conclusion

Thyrotoxicosis can cause dysregulation of catecholamines and is a rare cause of stress-induced cardiomyopathy. It requires distinct therapies and should be considered by emergency physicians in the workup of acute chest pain with concern for stress-induced cardiomyopathy.

Isolated calf deep venous thrombosis: frequency on venous ultrasound and clinical characteristics

Background

It remains controversial whether to include calf veins in the initial ultrasound evaluation of suspected deep venous thrombosis (DVT). We sought to investigate the frequency and clinical characteristics of isolated calf DVT.

Materials and methods

In this retrospective analysis, we investigated a cohort of 596 patients (median age 69 years, 52.3% women) who had been imaged with complete lower extremity venous duplex ultrasound for suspected acute DVT. Radiology reports were analyzed for the presence and localization of DVT. Clinical information was collected from patients’ electronic charts.

Results

DVT was found in 157 patients (26.3%), of which 74 patients (47.1%) had isolated calf DVT. Isolated calf DVTs were located in the posterior tibial veins (22 patients, 29.7%), peroneal veins (41 patients, 55.4%) and muscle veins (19 patients, 25.7%). There were no differences in age or sex between patients with isolated calf DVT and patients with proximal DVT. Isolated calf DVT was more commonly associated with leg pain (52.7% vs. 33.7%, p = 0.0234) and less commonly associated with subjective leg swelling (35.1% vs. 55.4%, p = 0.0158) and objectively measured difference in leg circumference (23% vs. 39.8%, p = 0.0268). D-Dimers were significantly lower in patients with isolated lower leg DVT (median 2.3 vs. 6.8 mg/L, p < 0.0001) compared to patients with proximal DVT.

Conclusions

Isolated calf DVT represents approximately half of DVT cases and has different clinical characteristics than proximal DVT.

AEM special issue on (in)equity in emergency medicine

The year of 2020 was a momentous one for the United States. A confluence of purposely-designed systems' outcomes and deep histories of schism converged with a viral mutation to force the topic of (in)justice to re-enter mainstream conversation. Not since the Civil Rights Movement has the matter of (in)equity been in the homes of so many U.S. families and the (virtual) offices of so many workplaces. The disproportionate deaths of Indigenous, Black, Asian, and Latinx peoples in relation to Whites is long-known in communities of color and is well documented in public health.

The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis

Acute lower extremity proximal deep venous thrombosis (DVT) requires accurate diagnosis and treatment in order to prevent embolization and other complications. Point-of-care ultrasound (POCUS), a clinician performed, and clinician interpreted bedside ultrasound examination has been increasingly used for DVT evaluation mainly in the urgent and critical care setting, but also in the ambulatory clinics and the medical wards. Studies have demonstrated that POCUS has excellent diagnostic accuracy for acute proximal DVT when performed by well-trained users. However, there is significant heterogeneity among studies on the necessary extent of training and universally acceptable standardized education protocols are needed. In this review, we summarize the evidence that supports the use of POCUS to diagnose acute proximal DVT and focus on methodology and current technology, sensitivity and specificity, pre-test probability and the role of D-dimer, time and resources, education, limitations, and future directions.

Current Awareness and Status of Venous Ultrasonography in Kumamoto Prefecture - A Report of the Kumamoto Cardiovascular Echocardiography Standardization Project

Background: There are few reports on the current awareness and status of venous ultrasonography, including the number of specialists who perform this procedure, in a specific regional area in Japan. Methods and Results: This cross-sectional survey study was conducted in Kumamoto Prefecture from October 2018 to March 2019. Of the 366 medical institutions providing cardiology services in Kumamoto Prefecture, 259 (101 general hospitals, 158 small clinics) responded to our questionnaire. In 2017, 21,773 venous ultrasound tests were performed, 21,101 (97%) of which were performed in hospitals and only 672 (3%) were performed in clinics. Both the number of institutions performing venous ultrasounds and the number of tests performed increased over time. Although 317 medical staff in Kumamoto Prefecture were performing transthoracic echocardiography (TTE) when the questionnaires were collected, only 210 performed venous ultrasounds. Although 91% (61/67) of medical institutions could perform TTE within 30 min, only 77% (53/69) performed venous ultrasounds within 30 min. The number of venous ultrasounds per population×100 was largest in the Kumamoto and Kamimashiki areas (1.67) and smallest in the Kamoto area (0.05). Conclusions: This is the first report to reveal the current awareness and status of venous ultrasonography in a specific region in Japan. There are several problems to be overcome, such as a lack of venous ultrasound specialists and the regional disparity in venous ultrasounds in Kumamoto Prefecture.

How I Do It: Point-of-Care Ultrasound for Bedside Diagnosis of Lower Extremity DVT

The point-of-care ultrasound (POCUS) DVT examination can facilitate rapid bedside diagnosis and treatment of lower extremity DVT. Awaiting radiology-performed Doppler ultrasonography and interpretation by radiologists can lead to delays in lifesaving anticoagulation, and the POCUS DVT examination can provide timely diagnostic information in the patient with lower extremity symptoms. This article outlines accepted techniques for the POCUS DVT examination, discusses the historical context from which the current recommendations have evolved, and provides illustrations alongside ultrasound images of relevant venous anatomy to orient the clinician. Finally, common pitfalls and methods to avoid them are described.

Point of care ultrasound screening for deep vein thrombosis in critically ill COVID-19 patients, an observational study

BACKGROUND

Deep vein thrombosis (DVT) is common in critically ill patients with Coronavirus disease 2019 (COVID-19) and may cause fatal pulmonary embolism (PE) prior to diagnosis due to subtle clinical symptoms. The aim of this study was to explore the feasibility of bedside screening for DVT in critically ill COVID-19 patients performed by physicians with limited experience of venous ultrasound. We further aimed to compare inflammation, coagulation and organ dysfunction in patients with and without venous thromboembolism (VTE).

METHODS

This observational study included patients with COVID-19 admitted to the intensive care unit (ICU) of a tertiary hospital in Sweden and screened for DVT with proximal compression ultrasound of the lower extremities between April and July 2020. Screening was performed by ICU residents having received a short online education and one hands-on-session. Pathological screening ultrasound was confirmed by formal ultrasound whereas patients with negative screening underwent formal ultrasound on clinical suspicion. Clinical data, laboratory findings and follow-up were extracted from medical records.

RESULTS

Of 90 eligible patients, 56 were screened by seven ICU residents with no (n = 5) or limited (n = 2) previous experience of DVT ultrasound who performed a median of 4 (IQR 2-19) examinations. Four (7.1%) patients had pathological screening ultrasound of which three (5.6%) were confirmed by formal ultrasound. None of the 52 patients with negative screening ultrasound were diagnosed with DVT during follow-up. Six patients were diagnosed with PE of which four prior to negative screening and two following negative and positive screening respectively. Patients with VTE (n = 8) had higher median peak D-dimer (24.0 (IQR 14.2-50.5) vs. 2.8 (IQR 1.7-7.2) mg/L, p = 0.004), mean peak C-reactive protein (363 (SD 80) vs. 285 (SD 108) mg/L, p = 0.033) and median peak plasma creatinine (288 (IQR 131-328) vs. 94 (IQR 78-131) μmol/L, p = 0.009) compared to patients without VTE (n = 48). Five patients (63%) with VTE received continuous renal replacement therapy compared to six patients (13%) without VTE (p = 0.005).

CONCLUSION

ICU residents with no or limited experience could detect DVT with ultrasound in critically ill COVID-19 patients following a short education. VTE was associated with kidney dysfunction and features of hyperinflammation and hypercoagulation.

TRIAL REGISTRATION

ClinicalTrials ID: NCT04316884 . Registered 20 March 2020.

Training pediatric residents in point-of-care ultrasound: An assessment of the needs and barriers to acquire the skill

Introduction

The use of point-of-care ultrasound (POCU) is increasing globally. However, owing to the epidemiology of diseases and local management strategies, POCU may not be universally applicable. Before developing a POCU training program, because of limited resources for medical education, it was pivotal to conduct a needs assessment and identify the training barriers.

Methods

This study used a validated paper questionnaire. The survey instrument was distributed to 120 pediatric residents (male 60, female 60) training at our institution to assess their self-reported level of skill in POCU, and their perceptions with regard to the applicability of POCU, measured with a 5-point Likert scale. The skills deficit was measured by subtracting the self-reported level of skills in lung, cardiac, and abdominal POCU from the perceived applicability of POCU.

Results

Fifty-nine residents participated, resulting in a response rate of 50 and 48% (n = 29) for the male group, and 50% (n = 30) for the female group. The level of knowledge and proficiency was low. Scanning for free abdominal fluid was deemed the most applicable (mean 4.2 ± SD 1.1); however, the use of POCU to detect consolidation was considered least applicable (mean 2.7 ± SD 1.3). The skills deficit was highest for an abdominal POCU (mean 2.4 ± SD 1.6) and lowest for lung ultrasound (mean 1.4 ± SD 1.6). Although the majority (n = 48) agreed that this skill was essential, 3 (5%) had no interest, and 39% (n = 23) indicated a lack of time to acquire the skill.

Conclusions

Though pediatric residents in Saudi Arabia agree that POCU is an essential skill, large skill deficits exist, supporting the necessity to provide POCU training. However, there are several barriers to overcome to achieve this.

Perioperative Point-of-Care Ultrasound Use by Anesthesiologists

Point-of-Care ultrasound (POCUS) is the bedside utilization of ultrasound, in real-time, to aid in the diagnosis and treatment of patients. Image acquisition from POCUS utilization by anesthesiologists involves the assessment of multiple organs in different perioperative situations. POCUS can be utilized to enhance clinical decision-making in a variety of perioperative situations due to its ability to assess endotracheal tube placement, cardiac function, pulmonary function, aspiration risk, hemodynamics, vascular access, and nerve visualization for regional procedures. The mounting clinical evidence for the value of POCUS in perioperative settings, its growing affordability, and its low associated risks are responsible for the nationwide movement across many anesthesiology residency programs to increase the focus on perioperative ultrasound training. The purpose of this review is to present to current anesthesiologists and anesthesiology trainees, a broad discussion regarding the diverse utility and importance of POCUS in perioperative settings.

Diagnosis of deep vein thrombosis of the lower extremity: a systematic review and meta-analysis of test accuracy

Deep vein thrombosis (DVT) of the lower extremities can be associated with significant morbidity and may progress to pulmonary embolism and postthrombotic syndrome. Early diagnosis and treatment are important to minimize the risk of these complications. We systematically reviewed the accuracy of diagnostic tests for first-episode and recurrent DVT of the lower extremities, including proximal compression ultrasonography (US), whole leg US, serial US, and high-sensitivity quantitative D-dimer assays. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 43 studies. For any suspected DVT, the pooled estimates for sensitivity and specificity of proximal compression US were 90.1% (95% confidence interval [CI], 86.5-92.8) and 98.5% (95% CI, 97.6-99.1), respectively. For whole-leg US, pooled estimates were 94.0% (95% CI, 91.3-95.9) and 97.3% (95% CI, 94.8-98.6); for serial US pooled estimates were 97.9% (95% CI, 96.0-98.9) and 99.8% (95% CI, 99.3-99.9). For D-dimer, pooled estimates were 96.1% (95% CI, 92.6-98.0) and 35.7% (95% CI, 29.5-42.4). Recurrent DVT studies were not pooled. Certainty of evidence varied from low to high. This systematic review of current diagnostic tests for DVT of the lower extremities provides accuracy estimates. The tests are evaluated when performed in a stand-alone fashion, and in a diagnostic pathway. The pretest probability of DVT often assessed by a clinical decision rule will influence how, together with sensitivity and specificity estimates, patients will be managed.

Introducing point-of-care ultrasound in Danish general practice-elucidating the use through a medical audit

BACKGROUND

Point-of-care ultrasonography (PoCUS) is increasingly used across the medical field. PoCUS is also being implemented in general practice despite a lack of clinical guidelines and training programs for general practitioners (GPs).

OBJECTIVES

This study aimed to elucidate the employment of PoCUS by Danish GPs following a short training program.

METHODS

Thirty GPs were enrolled in a short ultrasound training program and taught how to perform 22 selected scanning modalities. In the following 3 months, the GPs registered all performed PoCUS examinations according to the Audit Project Odense method. After 5 months, the GPs were invited to participate in an evaluation seminar, where questionnaires were distributed.

RESULTS

During the registration period, 1598 patients were examined with PoCUS. A total of 1948 scanning modalities were registered, including 207 examinations outside the taught curriculum. The majority of the ultrasound examinations were performed within 10 minutes (89%), most were considered to be conclusive (87%) and/or to increase diagnostic certainty (67%), whereas one in four examinations entailed a change in patient management. Most GPs attending the evaluation seminar continued to use PoCUS and found the scanning modalities included in the course curriculum relevant in their daily work.

CONCLUSION

The GPs found several indications for performing PoCUS following the attendance of a 2-day basic training program. The majority of examinations were registered to be conclusive and/or increase diagnostic certainty. However, few GPs used PoCUS on a daily basis and not all examinations were registered to have an impact on patient care.

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

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

Agreement between emergency physicians and radiologists for the diagnosis of deep venous thrombosis with compression ultrasound: a prospective study

INTRODUCTION

The time factor in diagnosis and management of a deep vein thrombosis of the lower extremities (LE DVT) is of increasing importance in the era of crowding of emergency departments (ED). Current techniques used to detect LE DVT include a two-point regional compression ultrasound (rCUS), yet assessments are usually performed only during office hours. Outside office hours ultrasonography is postponed and low molecular weight heparin (LMWH) prescribed.

OBJECTIVES

Primary outcome of the study was to assess the level of agreement in rCUS for LE DVT when performed by Dutch emergency physicians compared to rCUS by a radiologist. Secondary outcome was time to diagnosis.

METHOD

We performed a single-blind cohort study. All consecutive patients aged 18 years and older attending the ED with clinical suspicion of LE DVT were considered eligible for study enrolment. rCUS was ordered at the radiology department; subsequently, the bedside rCUS examination was also performed in the ED by the emergency physicians or ED residents.

RESULTS

A total of 138 patients were included, of whom 28 patients were diagnosed with DVT by a radiologist. Emergency physicians and radiologists showed comparable agreement [absolute agreement 94% (P < 0.001), Cohen's Kappa 0.87]. Emergency physicians decreased overall time to diagnosis by 01:04 h, ED residents showed comparable results. During out-of-office hours, time benefit was 16:39 h on weekdays and 18:40 h during weekends.

CONCLUSION

Emergency physicians show comparable agreement in diagnosing LE DVT using rCUS when compared to radiologists. Average time benefit is over an hour, thereby reducing unnecessary waiting and improving time to disposition. ED residents demonstrated similar results in both agreement and time-saving.

Follow-up of guidelines and impact on the management of suspected deep vein thrombosis in emergency departments

AIMS

To evaluate the implementation of the European Society of Cardiology (ESC) guidelines concerning the diagnostic management of deep vein thrombosis (DVT) in emergency departments (ED); and to estimate the additional financial cost and the increase in the time spent in the ED if the guidelines are not followed.

PATIENTS AND METHODS

Retrospective, bi-centric study including all patients directly admitted or referred to the ED for a suspected isolated DVT, between April 1, 2019, and July 30, 2019. The diagnostic management was compared to the 2017 ESC's guidelines.

RESULTS

107 patients were included, 13 had DVT (12%) and three had superficial venous thrombosis (3%). A total of 26 patients (24%) had a diagnostic management according to guidelines. In 72 patients (67%), no assessment of clinical probability score was found. Among the 35 patients in whom a clinical probability score was calculated, 5 patients had an unnecessary D-dimer assay and 2 patients had unjustified imaging. The median time spent in the ED was 185minutes when the recommendations were followed, and 250minutes when they were not (P=0.317). The total estimated additional cost was €232.20.

CONCLUSION

The rate of adherence to the guidelines is low, mainly due to the absence of calculation of a clinical probability. This leads, in addition to the risk of diagnostic error, to an increase in the time spent in the EDs and inappropriate use of the technical platform, resulting in additional costs of care.