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von Foerster N, Radomski MA, Martin-Gill C. Prehospital Ultrasound: A Narrative Review. PREHOSP EMERG CARE 2022; 28:1-13. [PMID: 36194192 DOI: 10.1080/10903127.2022.2132332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 10/31/2022]
Abstract
Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.
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Affiliation(s)
- Nicholas von Foerster
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marek A Radomski
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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2
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Rajamani A, Galarza L, Sanfilippo F, Wong A, Goffi A, Tuinman P, Mayo P, Arntfield R, Fisher R, Chew M, Slama M, Mackenzie D, Ho E, Smith L, Renner M, Tavares M, Prabu R N, Ramanathan K, Knudsen S, Bhat V, Arvind H, Huang S. Criteria, Processes, and Determination of Competence in Basic Critical Care Echocardiography Training: A Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative. Chest 2022; 161:492-503. [PMID: 34508739 DOI: 10.1016/j.chest.2021.08.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert opinion guidelines have guided BCCE competence educational standards and processes. However, existing guidelines lack precise detail due to methodological flaws during guideline development. RESEARCH QUESTIONS To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen: components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; and formative/summative assessment and final competence processes. STUDY DESIGN AND METHODS Between April 2020 and May 2021, a total of 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as Web-based questionnaires. Following each round, the agreement threshold for each item was determined as ≥ 80% for item inclusion and ≤ 30% for item exclusion. RESULTS Following rounds 1 and 2, agreement was reached on 62 of 114 items. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence, and final cognitive assessment. Items requiring multiple rounds included two-dimensional views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, and pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major vs minor and a standardized approach to errors, criteria for readiness for summative assessment, and supervisory options. INTERPRETATION In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, these recommendations require prospective validation.
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Affiliation(s)
- Arvind Rajamani
- University of Sydney Nepean Clinical School, Intensive Care Medicine, Kingswood, NSW, Australia; Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia.
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco," Catania, Italy
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Alberto Goffi
- Department of Critical Care Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto, Toronto, ON, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Pieter Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Paul Mayo
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY; Department of Pulmonary and Critical Care Medicine, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Robert Arntfield
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Richard Fisher
- Department of Critical Care, King's College Hospital, London, UK
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Michel Slama
- Medical Intensive Care, DRIME Department, University Hospital of Amiens, Amiens, France
| | - David Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - Eunise Ho
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China
| | - Louise Smith
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
| | - Markus Renner
- Department of Intensive Care Medicine, Dunedin Hospital, Dunedin, New Zealand; Otago University, New Zealand
| | - Miguel Tavares
- Department of Anesthesiology and Critical Care, Hospital Geral de Santo António, Porto, Portugal
| | - Natesh Prabu R
- Department of Critical Care Medicine, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Vijeth Bhat
- John Hunter Hospital, Intensive Care Unit, New Lambton Heights, NSW, Australia
| | | | - Stephen Huang
- University of Sydney Nepean Clinical School, Intensive Care Medicine, Kingswood, NSW, Australia
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3
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Ackil DJ, Toney A, Good R, Ross D, Germano R, Sabbadini L, Thiessen M, Bell C, Kendall JL. Use of Hand-motion Analysis to Assess Competence and Skill Decay for Cardiac and Lung Point-of-care Ultrasound. AEM EDUCATION AND TRAINING 2021; 5:e10560. [PMID: 34124508 PMCID: PMC8171793 DOI: 10.1002/aet2.10560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/31/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Assessment of competence in technical skills, including point-of-care ultrasound (POCUS), is required before a novice can safely perform the skill independently. Ongoing assessment of competence is also required because technical skills degrade over time, especially when they are infrequently performed or complex. Hand-motion analysis (HMA) is an objective assessment tool that has been used to evaluate competency in many technical skills. The purpose of this study was to demonstrate the feasibility and validity of HMA as an assessment tool for competence in both simple and complex technical skills as well as skill degradation over time. METHODS This prospective cohort study included 36 paramedics with no POCUS experience and six physicians who were fellowship trained in POCUS. The novices completed a 4-hour didactic and hands-on training program for cardiac and lung POCUS. HMA measurements, objective structured clinical examinations (OSCE), and written examinations were collected for novices immediately before and after training as well as 2 and 4 months after training. Expert HMA metrics were also recorded. RESULTS Expert HMA metrics for cardiac and lung POCUS were significantly better than those of novices. After completion of the training program, the novices improved significantly in all HMA metrics, knowledge test scores, and OSCE scores. Novices showed skill degradation in cardiac POCUS based on HMA metrics and OSCE scores while lung POCUS image acquisition skills were preserved. Novices deemed competent by OSCE score performed significantly better in HMA metrics than those not deemed competent. CONCLUSION We have demonstrated that HMA is a feasible and valid tool for assessment of competence in technical skills and can also evaluate skill degradation over time. Skill degradation appears more apparent in complex skills, such as cardiac POCUS. HMA may provide a more efficient and reliable assessment of technical skills, including POCUS, when compared to traditional assessment tools.
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Affiliation(s)
- Daniel J. Ackil
- From theDepartment of SurgeryDivision of Emergency MedicineUniversity of VermontLarner College of MedicineBurlingtonVTUSA
| | - Amanda Toney
- theDepartment of Pediatric Emergency MedicineUniversity of Colorado School of MedicineDenver Health Medical CenterDenverCOUSA
| | - Ryan Good
- theDepartment of PediatricsSection of Critical CareUniversity of Colorado School of MedicineAnschutz Medical Campus and Children’s Hospital ColoradoAuroraCOUSA
| | - David Ross
- theRocky Vista University College of Osteopathic MedicineParkerCOUSA
| | - Rocco Germano
- theFacolta di Medicina e ChirurgiaUniversita degli Studi di BresciaSpedali Civil di BresciaBresciaItaly
| | - Linda Sabbadini
- theFacolta di Medicina e ChirurgiaUniversita degli Studi di BresciaSpedali Civil di BresciaBresciaItaly
| | - Molly Thiessen
- and theDepartment of Emergency MedicineUniversity of Colorado School of MedicineDenver Health Medical CenterDenverCOUSA
| | - Colin Bell
- and theDepartment of Emergency MedicineQueen’s UniversityKingstonOntarioCanada
| | - John L. Kendall
- and theDepartment of Emergency MedicineUniversity of Colorado School of MedicineDenver Health Medical CenterDenverCOUSA
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Monti JD, Perreault MD. Impact of a 4-hour Introductory eFAST Training Intervention Among Ultrasound-Naïve U.S. Military Medics. Mil Med 2020; 185:e601-e608. [PMID: 32060506 DOI: 10.1093/milmed/usaa014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/23/2019] [Accepted: 05/22/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Advances in the portability of ultrasound have allowed it to be increasingly employed at the point of care in austere settings. Battlefield constraints often limit the availability of medical officers throughout the operational environment, leading to increased interest in whether highly portable ultrasound devices can be employed by military medics to enhance their provision of combat casualty care. Data evaluating optimal training for effective medic employment of ultrasound is limited however. This prospective observational cohort study's primary objective was to assess the impact of a 4-hour introductory training intervention on ultrasound-naïve military medic participants' knowledge/performance of the eFAST application. MATERIALS AND METHODS Conventional U.S. Army Medics, all naïve to ultrasound, were recruited from across JBLM. Volunteer participants underwent baseline eFAST knowledge assessment via a 50-question multiple-choice exam. Participants were then randomized to receive either conventional, expert-led classroom didactic training or didactic training via an online, asynchronously available platform. All participants then underwent expert-led, small group hands-on training and practice. Participants' eFAST performance was then assessed with both live and phantom models, followed by a post-course knowledge exam. Concurrently, emergency medicine (EM) resident physician volunteers, serving as standard criterion for trained personnel, underwent the same OSCE assessments, followed by a written exam to assess their baseline eFAST knowledge. Primary outcome measures included (1) post-course knowledge improvement, (2) eFAST exam technical adequacy, and (3) eFAST exam OSCE score. Secondary outcome measures were time to exam completion and diagnostic accuracy rate for hemoperitoneum and hemopericardium. These outcome measures were then compared across medic cohorts and to those of the EM resident physician cohort. RESULTS A total of 34 medics completed the study. After 4 hours of ultrasound training, overall eFAST knowledge among the 34 medics improved from a baseline mean of 27% on the pretest to 83% post-test. For eFAST exam performance, the medics scored an average of 20.8 out of a maximum of 22 points on the OSCE. There were no statistically significant differences between the medics who received asynchronous learning versus traditional classroom-based learning, and the medics demonstrated comparable performance to previously trained EM resident physicians. CONCLUSIONS A 4-hour introductory eFAST training intervention can effectively train conventional military medics to perform the eFAST exam. Online, asynchronously available platforms may effectively mitigate some of the resource requirement burden associated with point-of-care ultrasound training. Future studies evaluating medic eFAST performance on real-world battlefield trauma patients are needed. Skill and knowledge retention must also be assessed for this degradable skill to determine frequency of refresher training when not regularly performed.
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Affiliation(s)
- Jonathan D Monti
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, Washington 98431
| | - Michael D Perreault
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, Washington 98431
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Guy A, Bryson A, Wheeler S, McLean N, Kanji HD. A Blended Prehospital Ultrasound Curriculum for Critical Care Paramedics. Air Med J 2019; 38:426-430. [PMID: 31843154 DOI: 10.1016/j.amj.2019.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/24/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Point-of-care ultrasound is a nascent and growing area of prehospital care. Most previously described ultrasound curricula for paramedics examine a single type of ultrasound scan. Here, we describe the implementation and evaluation of a prehospital ultrasound curriculum using a blended model of traditional didactics and hands-on experience with online prereading. METHODS We recruited a prospective convenience sample of critical care paramedics without prior ultrasound experience to take part in a 2-day ultrasound course. All participants completed prereading modules built from online resources followed by a didactic review of the material and hands-on practice. Ultrasound examinations included extended focused abdominal sonography in trauma, cardiac ultrasound, thoracic ultrasound, and vascular ultrasound. A written examination evaluated ultrasound theory and image interpretation, and a practical examination evaluated image acquisition. RESULTS Seventeen critical care paramedics completed the course with a mean grade on the written examination of 76%, with 76% of paramedics achieving the predetermined passing mark of 70% or greater. All paramedics passed the practical examination. CONCLUSION The implementation of a prehospital critical care ultrasound program is feasible in our provincial emergency medical services system. Further assessment is necessary to determine future knowledge and skill retention as well as clinical application and utility in real-world settings.
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Affiliation(s)
- Andrew Guy
- University of British Columbia Royal College of Physicians and Surgeons Emergency Medicine Residency Program, Vancouver, British Columbia, Canada; Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Anthony Bryson
- University of British Columbia Royal College of Physicians and Surgeons Emergency Medicine Residency Program, Vancouver, British Columbia, Canada; Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen Wheeler
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Ambulance Service, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Neilson McLean
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Critical Care, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Ambulance Service, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Hussein D Kanji
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Critical Care, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Ambulance Service, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
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6
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Liu RB, Bogucki S, Marcolini EG, Yu CY, Wira CR, Kalam S, Daley J, Moore CL, Cone DC. Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases. PREHOSP EMERG CARE 2019; 24:297-302. [DOI: 10.1080/10903127.2019.1626955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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7
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Betcher J, Becker TK, Stoyanoff P, Cranford J, Theyyunni N. Military trainees can accurately measure optic nerve sheath diameter after a brief training session. Mil Med Res 2018; 5:42. [PMID: 30572931 PMCID: PMC6300875 DOI: 10.1186/s40779-018-0189-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diameter measurements using a brief didactic and hands-on training session. Optic nerve sheath diameter is a noninvasive surrogate marker for elevated intracranial pressure, and may be of value in remote military operations, where rapid triage decisions must be made without access to advanced medical equipment. METHODS Military trainees with minimal ultrasound experience were given a 5-min didactic presentation on optic nerve sheath diameter ultrasound. Trainees practiced optic nerve sheath diameter measurements guided by emergency physician ultrasound experts. Trainees then measured the optic nerve sheath diameter on normal volunteers. Following this, a trained physician measured the optic nerve sheath diameter on the same volunteer as a criterion standard. An average of three measurements was taken. RESULTS Twenty-three military trainees were enrolled. A mixed design ANOVA was used to compare measurements by trainees to those of physicians, with a mean difference of - 0.6 mm (P = 0.76). A Bland-Altman analysis showed that the degree of bias in optic nerve sheath diameter measures provided by trainees was very small: d = - 0.004 for the right eye and d = - 0.007 for the left eye. CONCLUSION This study demonstrates that optic nerve sheath diameter measurement can be accurately performed by novice ultrasonographers after a brief training session. If validated, point-of-care optic nerve sheath diameter measurement could impact the triage of injured patients in remote areas.
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Affiliation(s)
- Joseph Betcher
- Department of Emergency Medicine, Mercy Health Muskegon, 1500 E Sherman Blvd, Muskegon, MI, 49444, USA.
| | - Torben K Becker
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Peter Stoyanoff
- Department of Emergency Medicine, Hurley Hospital, 1 Hurley Plaza, Flint, MI, 48503, USA
| | - Jim Cranford
- Department of Psychiatry, University of Michigan, 1500 E Medical Center, Ann Arbor, MI, 48109, USA
| | - Nik Theyyunni
- Department of Emergency Medicine, University of Michigan, 1500 E Medical Center, Ann Arbor, MI, 48109, USA
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8
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Maddry JK, Perez CA, Mora AG, Lear JD, Savell SC, Bebarta VS. Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury and traumatic amputations: a retrospective study. Mil Med Res 2018; 5:22. [PMID: 29976254 PMCID: PMC6032797 DOI: 10.1186/s40779-018-0169-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and non-compressible torso injury (NCTI). METHODS We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI (AMP+NCTI), traumatic amputation only (AMP), and neither AMP nor NCTI (Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests, Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling. RESULTS We reviewed 1267 records, of which 669 had an injury severity score (ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries (n=104, AMP only), 10.8% sustained amputation and NCTI (n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI (n=493, Non-AMP/NCTI). AMP+NCTI had the highest mortality (16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend. CONCLUSIONS A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.
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Affiliation(s)
- Joseph K Maddry
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, San Antonio Military Medical Center, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Crystal A Perez
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Alejandra G Mora
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Jill D Lear
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Shelia C Savell
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.
| | - Vikhyat S Bebarta
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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9
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McCallum J, Vu E, Sweet D, Kanji HD. Assessment of Paramedic Ultrasound Curricula: A Systematic Review. Air Med J 2016; 34:360-8. [PMID: 26611224 DOI: 10.1016/j.amj.2015.07.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/10/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prehospital ultrasound is being applied in the field. The purpose of this systematic review is to describe evidence pertaining to ultrasound curricula for paramedics specifically, including content, duration, setting, design, evaluation, and application. METHODS Electronic searches of MEDLINE, Embase, CINAHL, and the Cochrane Center Register of Controlled Trials were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary literature describing acute care ultrasound curricula for paramedics were included. Two authors independently extracted data and assessed quality using 2 validated tools. RESULTS Twelve studies with 187 paramedics were included. Curricula duration varied, with effective curricula teaching focused assessment with sonography for trauma (FAST) in 6 to 8 hours and pleural ultrasound in 25 minutes. FAST, pleural, and fracture-detection ultrasound are being applied in the field by paramedics; however, no literature exists describing application to detect cardiac standstill. Curricula combined didactic and hands-on components including simulation and evaluated competency using sensitivity and specificity of paramedic-performed ultrasound. CONCLUSIONS Paramedic ultrasound curricula in FAST and pleural ultrasound is feasible and time effective with successful application. Although fracture detection ultrasound is being used by the special operations forces, no comprehensive curriculum was described. Curricula designed to detect cardiac standstill have been too short, and successful application by paramedics has not been shown.
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Affiliation(s)
- Jessica McCallum
- Student, University of British Columbia MD Undergraduate Program, Vancouver, BC, Canada
| | - Erik Vu
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Emergency Health Services, Provincial AirEvac & Critical Care Operations, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - David Sweet
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - Hussein D Kanji
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
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10
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Rooney KP, Lahham S, Lahham S, Anderson CL, Bledsoe B, Sloane B, Joseph L, Osborn MB, Fox JC. Pre-hospital assessment with ultrasound in emergencies: implementation in the field. World J Emerg Med 2016; 7:117-23. [PMID: 27313806 DOI: 10.5847/wjem.j.1920-8642.2016.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%). CONCLUSION Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.
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Affiliation(s)
- Kevin P Rooney
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202, USA
| | - Sari Lahham
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - Shadi Lahham
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - Craig L Anderson
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - Bryan Bledsoe
- Emergency Medicine, University of Nevada School of Medicine, Las Vegas, Nevada 89102, USA
| | - Bryan Sloane
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - Linda Joseph
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - Megan B Osborn
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
| | - John C Fox
- Emergency Medicine, University of California, Irvine, Orange, California 92868, USA
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11
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O'Dochartaigh D, Douma M. Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review. Injury 2015; 46:2093-102. [PMID: 26264879 DOI: 10.1016/j.injury.2015.07.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital. OBJECTIVE This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient. METHODS A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed. RESULTS 992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomised controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomised observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management. CONCLUSION There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.
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Affiliation(s)
- D O'Dochartaigh
- Air Medical Crew, Shock Trauma Air Rescue Society, Suite 100, 1519 35 Ave E, Edmonton Int'l Airport, Alberta T9E 0V6, Canada.
| | - M Douma
- Clinical Nurse Educator, Emergency Services, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, Alberta T5H 3V9, Canada.
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Bhat SR, Johnson DA, Pierog JE, Zaia BE, Williams SR, Gharahbaghian L. Prehospital Evaluation of Effusion, Pneumothorax, and Standstill (PEEPS): Point-of-care Ultrasound in Emergency Medical Services. West J Emerg Med 2015; 16:503-9. [PMID: 26265961 PMCID: PMC4530907 DOI: 10.5811/westjem.2015.5.25414] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 12/05/2022] Open
Abstract
Introduction In the United States, there are limited studies regarding use of prehospital ultrasound (US) by emergency medical service (EMS) providers. Field diagnosis of life-threatening conditions using US could be of great utility. This study assesses the ability of EMS providers and students to accurately interpret heart and lung US images. Methods We tested certified emergency medical technicians (EMT-B) and paramedics (EMT-P) as well as EMT-B and EMT-P students enrolled in prehospital training programs within two California counties. Participants completed a pre-test of sonographic imaging of normal findings and three pathologic findings: pericardial effusion, pneumothorax, and cardiac standstill. A focused one-hour lecture on emergency US imaging followed. Post-tests were given to all EMS providers immediately following the lecture and to a subgroup one week later. Results We enrolled 57 prehospital providers (19 EMT-B students, 16 EMT-P students, 18 certified EMT-B, and 4 certified EMT-P). The mean pre-test score was 65.2%±12.7% with mean immediate post-test score of 91.1%±7.9% (95% CI [22%–30%], p<0.001). Scores significantly improved for all three pathologic findings. Nineteen subjects took the one-week post-test. Their mean score remained significantly higher: pre-test 65.8%±10.7%; immediate post-test 90.5%±7.0% (95% CI [19%–31%], p<0.001), one-week post-test 93.1%±8.3% (95% CI [21%–34%], p<0.001). Conclusion Using a small sample of EMS providers and students, this study shows the potential feasibility for educating prehospital providers to accurately identify images of pericardial effusion, pneumothorax, and cardiac standstill after a focused lecture.
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Affiliation(s)
- Sundeep R Bhat
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California ; Kaiser Permanente Santa Clara Medical Center, Department of Emergency Medicine, Santa Clara, California
| | - David A Johnson
- Emergency Medicine Physicians, Department of Emergency Medicine, Mecklenberg, North Carolina
| | - Jessica E Pierog
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Brita E Zaia
- Kaiser Permanente San Francisco Medical Center, Department of Emergency Medicine, San Francisco, California
| | - Sarah R Williams
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Laleh Gharahbaghian
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
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Horowitz R, Gossett JG, Bailitz J, Wax D, Pierce MC. The FLUSH Study—Flush the Line and Ultrasound the Heart: Ultrasonographic Confirmation of Central Femoral Venous Line Placement. Ann Emerg Med 2014; 63:678-83. [DOI: 10.1016/j.annemergmed.2013.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 12/07/2013] [Accepted: 12/17/2013] [Indexed: 12/20/2022]
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Taylor J, McLaughlin K, McRae A, Lang E, Anton A. Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors. BMC Emerg Med 2014; 14:6. [PMID: 24580744 PMCID: PMC3941255 DOI: 10.1186/1471-227x-14-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 02/25/2014] [Indexed: 12/19/2022] Open
Abstract
Background Advances in ultrasound imaging technology have made it more accessible to prehospital providers. Little is known about how ultrasound is being used in the prehospital environment and we suspect that it is not widely used in North America at this time. We believe that EMS system characteristics such as provider training, system size, population served, and type of transport will be associated with use or non-use of ultrasound. Our study objective was to describe the current use of prehospital ultrasound in North America. Methods This study was a cross-sectional survey distributed to EMS directors on the National Association of EMS Physicians (NAEMSP) mailing list. Respondents had the option to complete a paper or electronic survey. Results Of the 755 deliverable surveys we received 255 responses from across Canada and the United states for an overall response rate of 30%. Of respondents, 4.1% of EMS systems (95% CI 1.9, 6.3) reported currently using ultrasound and an additional 21.7% (95% CI 17, 26.4) are considering implementing ultrasound. EMS services using ultrasound have a higher proportion of physicians (p < 0.001) as their highest trained prehospital providers when compared to the survey group as a whole. The most commonly cited current and projected applications are Focused Abdominal Sonography for Trauma (FAST) and assessment of pulseless electrical activity (PEA) arrest. The cost of equipment and training are the most significant barriers to implementation of ultrasound. Most medical directors want evidence that prehospital ultrasound improves patient outcomes prior to implementation. Conclusions Prehospital ultrasound is infrequently used in North America and there are a number of barriers to its implementation, including costs of equipment and training and limited evidence demonstrating improved outcomes. A research agenda for prehospital ultrasound should focus on patient-important outcomes such as morbidity and mortality. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest.
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Affiliation(s)
- John Taylor
- University of Calgary MD program, #108 1990 West 6 Avenue, Vancouver, BC V6J 4V4, Canada.
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Abstract
There has been a recent explosion of education and training in echocardiography in the specialties of anesthesiology and critical care. These devices, by their impact on clinical management, are changing the way surgery is performed and critical care is delivered. A number of international bodies have made recommendations for training and developed examinations and accreditations.The challenge to medical educators in this area is to deliver the training needed to achieve competence into already over-stretched curricula.The authors found an apparent increase in the use of simulators, with proven efficacy in improving technical skills and knowledge. There is still an absence of evidence on how it should be included in training programs and in the accreditation of certain levels.There is a conviction that this form of simulation can enhance and accelerate the understanding and practice of echocardiography by the anesthesiologist and intensivists, particularly at the beginning of the learning curve.
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Rudolph SS, Sørensen MK, Svane C, Hesselfeldt R, Steinmetz J. Effect of prehospital ultrasound on clinical outcomes of non-trauma patients--a systematic review. Resuscitation 2013; 85:21-30. [PMID: 24056394 DOI: 10.1016/j.resuscitation.2013.09.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/18/2013] [Accepted: 09/15/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Advances in technology have made prehospital ultrasound (US) examination available. Whether US in the prehospital setting can lead to improvement in clinical outcomes is yet unclear. OBJECTIVE The aim of this systematic review was to assess whether prehospital US improves clinical outcomes for non-trauma patients. METHOD We conducted a systematic review on non-trauma patients who had an US examination performed in the prehospital setting. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the ISI Web of Science and the references of the included studies for additional relevant studies. We then performed a risk of bias analysis and descriptive data analysis. RESULTS We identified 1707 unique citations and included ten studies with a total of 1068 patients undergoing prehospital US examination. Included publications ranged from case series to non-randomized, descriptive studies, and all showed a high risk of bias. The large heterogeneity between the different studies made further statistical analysis impossible. CONCLUSION There are currently no randomized, controlled studies on the use of US for non-trauma patients in the prehospital setting. The included studies were of large heterogeneity and all showed a high risk of bias. We were thus unable to assess the effect of prehospital US on clinical outcomes. However, consistent reports suggested that US may improve patient management with respect to diagnosis, treatment, and hospital referral.
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Affiliation(s)
- Søren Steemann Rudolph
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark.
| | | | - Christian Svane
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
| | - Rasmus Hesselfeldt
- Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
| | - Jacob Steinmetz
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
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Chin EJ, Chan CH, Mortazavi R, Anderson CL, Kahn CA, Summers S, Fox JC. A pilot study examining the viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. J Emerg Med 2012; 44:142-9. [PMID: 22595631 DOI: 10.1016/j.jemermed.2012.02.032] [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: 07/18/2011] [Revised: 10/29/2011] [Accepted: 02/22/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field. STUDY OBJECTIVE To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. METHODS This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians--paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images. RESULTS All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6-9.6). CONCLUSION Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.
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Affiliation(s)
- Eric J Chin
- San Antonio Uniformed Services Health Education Consortium-San Antonio Military Medical Center, Ft. Sam Houston, Texas, USA
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Kim CH, Shin SD, Song KJ, Park CB. Diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations performed by emergency medical technicians. PREHOSP EMERG CARE 2012; 16:400-6. [PMID: 22385014 DOI: 10.3109/10903127.2012.664242] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We aimed to assess the diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations when used by emergency medical technicians (EMTs) to detect the presence of free abdominal fluid. METHODS Six level 1 EMTs (similar to intermediate EMTs in the United States) who worked at a tertiary emergency department in Korea underwent an educational program consisting of two one-hour didactic lectures that included the principles of ultrasonography, the anatomy of the abdomen, and two hours of hands-on practice. After this educational session, the EMTs performed FAST examinations on a convenience sample of patients from July 1 to October 5, 2009. These patients also received an abdominal computed tomography (CT) scan regardless of their chief complaints. The CT findings served as the definitive standard and were interpreted routinely and independently by emergency radiologists who were blinded to the study protocol. In addition, the EMTs were blinded to the CT findings. A positive CT finding was defined as the presence of free fluid, as interpreted by the radiologist. The sensitivity, specificity, predictive values, and their 95% confidence intervals (CIs) were calculated. Informed consent was obtained from all participating patients. RESULTS Among the 1,060 eligible patients with abdominal CT scans, 403 patients were asked to participate in the study, and 240 patients agreed. Of these 240 patients, 80 (33.3%) had results showing the presence of free fluid. Fourteen patients had a significant amount of peritoneal cavity fluid, 15 had a moderate amount of peritoneal cavity fluid, and 51 had a minimal amount of peritoneal cavity fluid. Compared with the CT findings, the diagnostic performance of the FAST examination had a sensitivity of 61.3% (95% CI, 50.3%-71.2%), specificity of 96.3% (95% CI, 92.1%-98.3%), positive predictive value of 89.1% (95% CI, 77.0%-95.4%), and negative predictive value of 83.2% (95% CI, 76.9%-88.2%). For a significant or moderate amount of peritoneal cavity fluid, the sensitivity was considerably higher (86.2%). CONCLUSION EMTs in Korea showed a high diagnostic performance that was comparable to that of surgeons and physicians when detecting peritoneal cavity free fluid in a Korean emergency department setting. The validity of FAST examinations in prehospital care situations should be investigated further.
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Affiliation(s)
- Chu Hyun Kim
- Department of Emergency Medicine, Inje University College of Medicine, Seoul, Republic of Korea
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