Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis.

BACKGROUND: Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children. METHODS: A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated. RESULTS: Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%. CONCLUSION: The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial.

BACKGROUND: Patients with traumatic wounds frequently present to the ED. Literature on whether to treat these wounds sterile or non-sterile is sparse. Non-sterile treatment has the advantage of saving resources and costs, and could be of value in health settings where sterile materials are not readily available. Our objective was to compare the rate of wound infection after suturing traumatic lacerations with non-sterile gloves and dressings versus sterile gloves, dressings and drapes in the ED. We hypothesised that non-sterile gloves and dressings would be non-inferior to sterile gloves, dressings and drapes. The non-inferiority margin was set at 2%. METHODS: A multicentre single-blinded randomised controlled trial testing for non-inferiority of non-sterile gloves and dressings versus sterile gloves, dressings and drapes for suturing of traumatic wounds was performed in 3 EDs in The Netherlands. Adults with uncomplicated wounds were included from July 2012 to December 2016. At the time of treatment, patient and wound characteristics and management were documented. The outcome was wound infection, which was identified during follow-up in the treating ED at 5-14 days postprocedure. RESULTS: From 2468 eligible patients, 1480 were randomised in a sterile (n=747) or non-sterile (n=733) protocol. Baseline characteristics were similar in both study arms. The observed wound infection rate in the non-sterile group was 5.7% (95% CI 4.0% to 7.5%) vs 6.8% (95% CI 5.1% to 8.8%) in the sterile group. The mean difference of the wound infection rate of the two groups was -1.1% (95% CI -3.7% to 1.5%). CONCLUSION: Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves, dressings and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED. TRIAL REGISTRATION NUMBER: NL 34798.078.11, NTR3541.

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.