A randomized trial of ultrasound-guided peripheral IV catheter placement in difficult access patients using a guidewire approach.

OBJECTIVE: The purpose of this pilot study was to investigate whether use of a guidewire improves successful placement of ultrasound-guided peripheral IVs (PIV) in difficult intravenous access patients in the emergency department (ED). METHODS: This was an unblinded, prospective, randomized trial performed by emergency medicine (EM) clinicians at a single academic ED. Eligible participants were randomized to ultrasound-guided PIV placement with or without the use of a guidewire. PIV access was obtained using the Accucath™ 20 gauge × 5.7 cm catheters by way of deployment or non-deployment of the guidewire. Primary outcome measure was first-pass success rate and secondary outcomes included number of attempts, complication rates, and clinician reported ease of insertion. RESULTS: Seventy patients were enrolled and 69 were included in the final analysis. Thirty-four participants were randomized to use of guidewire and 35 to no guidewire. First-pass success rates were similar with and without guidewire use, 47.1% vs. 45.7%, (p = 0.9). There were no differences found in median number of attempts between the two techniques, 2 (IQR 1-2) vs 2 (IQR 1-2), (p = 0.60). The complication rates were similar, 15% vs. 29% (p = 0.25). Clinicians reported no difference in ease of insertion between methods on a 5-point Likert Scale, mean 2.6 vs 2.7 (p = 0.76). DISCUSSION: In this pilot study comparing ultrasound-guided PIV placement in ED patients using an integrated guidewire versus no guidewire, there was no significant difference in first-pass success, number of attempts, or complication rates. This study provides preliminary data for further investigations.

Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound.

OBJECTIVE: The study objective was to investigate the combined accuracy of right heart strain on focused cardiac ultrasound (FOCUS) and deep vein thrombosis (DVT) on compression ultrasound (CUS) for identification of centrally located pulmonary embolism (PE) diagnosed on computed tomography pulmonary angiography (CTPA). METHODS: This was a prospective observational study using a convenience sample of patients undergoing CTPA in the emergency department (ED) for evaluation of PE. Patients received a FOCUS looking for right heart strain (McConnell's sign, septal flattening, right ventricular enlargement or tricuspid annular plane systolic ejection (TAPSE) <17mm) and a CUS looking for DVT. Ultrasounds were interpreted by both the investigator performing the ultrasound and the principal investigator independently. RESULTS: There were 199 patients enrolled in the study, with 46/199 (23.1%) positive for a PE. Of these, 20/46 (43.5%) PE's were located centrally. Of those with a PE, 20/46 (43.5%) had an associated DVT identified on bedside ultrasound. Among patients with a proximal PE, 18/20 (90.0%) had evidence of right heart strain and the combination of lower extremity CUS and FOCUS was 100% sensitive. Diagnostic accuracy of ultrasound was much lower for peripherally located PEs. CONCLUSIONS: Emergency physician-performed bedside ultrasound may be sufficient to exclude the presence of centrally located PE, as the sensitivity in this study was 100%. Additionally, several patients with PE may qualify for early anticoagulation when DVT is identified, and further research in indicated to determine whether these patients ultimately require CTPA given identical treatment algorithms in the absence of RV strain or biomarker elevation.

Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals.

OBJECTIVES: Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies. METHODS: We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy. RESULTS: Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28-2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%). CONCLUSIONS: A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

OBJECTIVE: We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. METHODS: This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. RESULTS: Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). CONCLUSIONS: Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

Evaluation of the Aortic Arch from the Suprasternal Notch View Using Focused Cardiac Ultrasound.

BACKGROUND: The suprasternal notch view (SSNV) is an additional echocardiographic view not routinely used by emergency physicians (EPs) performing focused cardiac ultrasound (FOCUS). OBJECTIVE: This pilot study determined the ease and self-perceived accuracy of the SSNV as performed by EPs. Additionally, we assessed the accuracy of FOCUS including the SSNV in thoracic aortic measurements compared to chest CT angiography (CTA). METHODS: This was a prospective, observational, pilot study of adult patients undergoing chest CTA. Thoracic aortic measurements were recorded at the sinus of Valsalva, sinotubular junction, and ascending aorta at its widest diameter in the parasternal long axis (PSL) view and SSNV. EPs rated ease of acquisition and self-perceived accuracy of thoracic aorta measurements. Two blinded radiologists performed thoracic aortic CTA measurements at predefined locations corresponding to the ultrasound measurements. RESULTS: Of the 79 patients (median age 57 years) enrolled, the SSNV was obtained in 97% of cases. EPs rated the ease of obtaining the SSNV as "easy" in 64.5% of cases and "very difficult" in 7.6% of cases. The mean difference between ultrasound (FOCUS plus SSNV) and CTA measurements were 1.2 mm (95% limits of agreement -2.9 to 5.3) at the sinus of Valsalva, 1.0 mm (95% limits of agreement -5.5 to 3.6 mm) at the sinotubular junction, 0.8 mm (95% limits of agreement -6.2 to 4.6 mm) at the proximal ascending aorta, and 0.6 mm (95% limits of agreement -2.8 to 4.0) at the aortic arch. CONCLUSIONS: Our findings suggest that the SSNV is an easily attainable and accurate view of the thoracic aorta that can be obtained by EPs in the majority of ED patients.

A practical guide to self-sustaining point-of-care ultrasound education programs in resource-limited settings.

The value of point-of-care ultrasound education in resource-limited settings is increasingly recognized, though little guidance exists on how to best construct a sustainable training program. Herein we offer a practical overview of core factors to consider when developing and implementing a point-of-care ultrasound education program in a resource-limited setting. Considerations include analysis of needs assessment findings, development of locally relevant curriculum, access to ultrasound machines and related technological and financial resources, quality assurance and follow-up plans, strategic partnerships, and outcomes measures. Well-planned education programs in these settings increase the potential for long-term influence on clinician skills and patient care.

Positive FAST without hemoperitoneum due to fluid resuscitation in blunt trauma.

BACKGROUND: The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. OBJECTIVES: To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. CASE REPORT: We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. CONCLUSION: This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED). OBJECTIVES: OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography. CASE REPORT: We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles. CONCLUSIONS: This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.

Using lung ultrasound to differentiate patients in acute dyspnea in the prehospital emergency setting.

The diagnosis and treatment of dyspnea in the emergency department and in the prehospital setting is a challenge faced by the emergency physician and other prehospital care providers. While the use of lung ultrasound as a diagnostic tool in dyspneic patients has been well researched, there has been limited evaluation of its use in the prehospital setting. In the previous issue of Critical Care, Prosen and colleagues study the accuracy of lung ultrasound compared with both N-terminal pro-brain natriuretic peptide and the clinical examination for differentiating between acute decompensated congestive heart failure and chronic obstructive pulmonary disease exacerbations for patients in the prehospital setting. Their article adds to the growing body of evidence demonstrating the diagnostic efficacy of lung ultrasound in differentiating between these two disease processes in the acutely dyspneic patient.

Patient with progressive chest pain and dyspnea after aortic valve replacement.

A 45-year-old man presented to the emergency department (ED) with progressive chest pain and dyspnea 3 months after aortic valve replacement. He had been evaluated by his primary care physician and cardiologist and no diagnosis had been made. On arrival, the emergency physicians performed point-of-care ultrasonography, which showed a large hypoechoic collection compressing the right ventricle. This prompted further workup, including a computed tomography of the chest, which revealed a large fluid collection in the anterior mediastinum. Subsequently, cardiothoracic surgery was consulted and the patient was taken to the operating room for a sternal washout with evacuation of the collection.

Correlation of OSCE performance and point-of-care ultrasound scan numbers among a cohort of emergency medicine residents.

BACKGROUND: Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150-300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). METHODS: This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. RESULTS: Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343-361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289-409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351-360], which was slightly higher than the median OSCE score of 342 [IQR 326-361] in the group with less than 300 total scans (p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. CONCLUSION: The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.