The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea.

PURPOSE: This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS: The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS: A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION: The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.

Adding trans-abdominal elastography to the diagnostic tool for an ileal gastrointestinal stromal tumor: a case report.

BACKGROUND: Diagnosis of gastrointestinal stromal tumors (GISTs) in the distal small intestine is difficult by endoscopic ultrasound. This is the first reported case of an ileal GIST, which is diagnosed by transabdominal sonography and strain elastography. CASE PRESENTATION: A 75 y/o woman presented with tarry stool and dizziness. No definite bleeder could be identified by esophagogastroduodenoscopy and colonoscopy. The transabdominal sonography revealed a large heterogeneous tumor involving the muscular layer of the ileum. Strain elastography showed the strain ratio was 6.51. Strain histogram was skewed to the blue side, and mean color value was 230.5, signifying a stiff tumor. GIST was highly suspected. The patient underwent laparoscope-assisted tumor excision and the histological examination confirmed a malignant GIST. The patient was discharged without postoperative event. CONCLUSION: Transabdominal strain elastography could play a role to discriminate small bowel GISTs and other submucosal tumors, especially in the location with difficulty in endoscopic ultrasound.

Palpebral emphysema following a dental procedure.

Palpebral emphysema is a rare occurrence after a dental procedure. However, it can be associated with severe complications, such as soft tissue infection, pneumomediastinum, pneumothorax, optic nerve ischemia or even blindness. Early diagnosis and prompt management are mandatory for emergency physicians.

The effect of e-learning on point-of-care ultrasound education in novices.

BACKGROUND: Current studies assessed the learning efficacy of e-learning in ultrasound (US) training using questionnaires, or simulation in well-controlled conditions. This study investigates the effect of e-learning on the clinical US performance of the first postgraduate year (PGY-1) residents. METHODS: In this prospective observational study, we enrolled PGY-1 and second postgraduate year (PGY-2) residents. The e-learning was introduced on the first day and each PGY-1 was authorized to access the e-learning platform. The point-of-care ultrasound (PoCUS) curriculum for the focused assessment of sonography for trauma (FAST) was conducted on the 7th day for PGY-1 and the objective structured clinical examination (OSCE) followed. The PGY-2 received bedside one-to-one random learning before the study and did not have the authorization to access the e-learning. The FAST examinations performed by the PGY-1 and PGY-2 were collected on the 30th day. The clinical FAST performance was assessed by the instructor not involved in the curriculum and blinded to the use of e-learning, including numbers, image quality, and diagnostic accuracy between PGY-1 e-learning users, non-users, and the PGY-2. RESULTS: One hundred and seventy PGY-1 with 736 FAST examinations and 53 PGY-2 residents with 134 examinations were included. Seventy PGY-1 used e-learning with a median time spent of 13.2 mins (IQR, 6.5-21.1 mins) at the first access. The PGY-2 had more PoCUS experience than the PGY-1, however, the 70 e-learning users performed more FAST examinations than the PGY-2 (median [IQR], 4 [2-6] vs. 2 [1-3], p = 0.0004) and had better image quality than the PGY-2 (3 [3-3.2] vs. 3 [2.7-3], p = 0.044). There were no significant differences in the diagnostic accuracy between the PGY-1 and PGY-2. CONCLUSIONS: E-learning has a positive effect on US learning. The PGY-1 users had comparable performance with the PGY-2 and even better image acquisition although the PGY-2 had more PoCUS experience. TRIAL REGISTRATION: NCT03738033 at ClinicalTrials.gov.

Impact of Ultrasonography on Chest Compression Fraction and Survival in Patients with Out-of-hospital Cardiac Arrest.

INTRODUCTION: Whether ultrasonography (US) contributes to delays in chest compressions and hence a negative impact on survival is uncertain. In this study we aimed to investigate the impact of US on chest compression fraction (CCF) and patient survival. METHODS: We retrospectively analyzed video recordings of the resuscitation process in a convenience sample of adult patients with non-traumatic, out-of-hospital cardiac arrest. Patients receiving US once or more during resuscitation were categorized as the US group, while the patients who did not receive US were categorized as the non-US group. The primary outcome was CCF, and the secondary outcomes were the rates of return of spontaneous circulation (ROSC), survival to admission and discharge, and survival to discharge with a favorable neurological outcome between the two groups. We also evaluated the individual pause duration and the percentage of prolonged pauses associated with US. RESULTS: A total of 236 patients with 3,386 pauses were included. Of these patients, 190 received US and 284 pauses were related to US. Longer resuscitation duration was observed in the US group (median, 30.3 vs 9.7 minutes, P<.001). The US group had comparable CCF (93.0% vs 94.3%, P=0.29) with the non-US group. Although the non-US group had a better rate of ROSC (36% vs 52%, P=0.04), the rates of survival to admission (36% vs 48%, P=0.13), survival to discharge (11% vs 15%, P=0.37), and survival with favorable neurological outcome (5% vs 9%, P=0.23) did not differ between the two groups. The pause duration of pulse checks with US was longer than pulse checks alone (median, 8 vs 6 seconds, P=0.02). The percentage of prolonged pauses was similar between the two groups (16% vs 14%, P=0.49). CONCLUSION: When compared to the non-ultrasound group, patients receiving US had comparable chest compression fractions and rates of survival to admission and discharge, and survival to discharge with a favorable neurological outcome. The individual pause was lengthened related to US. However, patients without US had a shorter resuscitation duration and a better rate of ROSC. The trend toward poorer results in the US group was possibly due to confounding variables and nonprobability sampling. It should be better investigated in further randomized studies.

Clinical utilization of point-of-care ultrasound by junior emergency medicine residents.

AIM: Little is known regarding the actual utilization of point-of-care ultrasound (PoCUS) after training. This study aims to investigate the clinical utilization of PoCUS by first post-graduate year (PGY-1) residents after training. MATERIAL AND METHODS: This prospective study was conducted at the emergency department (ED). A PoCUS curriculum was implemented and the objective structured clinical examination (OSCE) scores were obtained after training. The sonographic examinations performed by the residents were collected. The primary outcomes were the numbers, imaging quality, and accuracy of the sonographic examinations after the curriculum, compared with those before the curriculum. RESULTS: Two hundred and thirtynine residents participated with the median OSCE score of 4 (IQRs, 4-5) and 170 (71%) used PoCUS during clinical practice. The number that each resident performed increased [before vs. after, 0 (0-1) vs. 3 (0-5), p<0.0001], the image quality was better [before vs. after, 3 (2-3) vs. 3 (3), p<0.0001] and the accuracy improved (before vs. after, 117/129 vs. 730/772, p<0.0001) after the curriculum. The residents were categorized into 4 groups based on the utilization: group 1 performed PoCUS before and after the curriculum; group 2 performed only after the curriculum; group 3 performed only before the curriculum; the last did not use. No significant differences existed in the OSCE score between the 4 groups. Group 1 performed more examinationswith better image quality and groups 1 and 2 used ≥2 applications after the curriculum. However, nearly 30% of residents did not use PoCUS, and "chose other imaging priorities" (40/69, 58%) was the main feedback. CONCLUSIONS: A PoCUS training had a positive impact on the clinical utilization by the novice residents. More than 70% of residents integrated PoCUS into clinical practice and used self-formatted US techniques. The OSCE scores could not predict further utilization.

Ultrasonographic Assessment During Cardiopulmonary Resuscitation.

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, airway, and breathing status of a patient during cardiopulmonary resuscitation (CPR) in an advanced life support-compliant manner. US-C provides a subxiphoid view of the heart, to look for potentially reversible causes of disease, such as pericardial effusion, pulmonary embolism, hypovolemia, and acute coronary thrombosis. Sonographic cardiac activity during CPR not only helps differentiate pseudo-pulseless electrical activity (PEA) from true PEA but also represents a higher chance of the return of spontaneous circulation (ROSC) and survival. Evaluation of the inferior vena cava (IVC) shows the fluid status of the patient and indicates the best methods to use for fluid resuscitation. If aortic dissection is suspected, a subxiphoid view of the aorta is suggested for identifying an intimal flap. Once intubation is done, tracheal ultrasound (US-A) at the suprasternal notch helps differentiate endotracheal intubation (one air-mucosal interface with one comet-tail) from esophageal intubation (double tract sign). Immediately following US-A, bilateral lung US (US-B) should be done to confirm proper bilateral ventilation using the lung sliding sign. In addition, US-C can be serially followed to see the dynamic changes in the cardiac chambers and IVC, or any cardiac contraction suggestive of ROSC. US-B can also detect coexisting lung or pleural pathologies without interfering with the performance of CPR. The main concern when implementing this method is maintaining high-quality CPR without delays in chest compressions when performing US-CAB. Rigorous training and continued practice are key to minimize any interruptions during resuscitation.