A pilot study examining the use of ultrasound to measure sarcopenia, frailty and fall in older patients.

INTRODUCTION: The importance of this study is to devise an efficient tool for assessing frailty in the ED. The goals of this study are 1) to correlate ultrasonographic (US) measurements of muscle thickness in older ED patients with frailty and 2) to correlate US-measured sarcopenia with falls, subsequent hospitalizations and ED revisits. METHODS: Participants were conveniently sampled from a single ED in this prospective cohort pilot study of patients aged 65 or older. Participants completed a Fatigue, Resistance, Ambulation, Illness and Loss of Weight (FRAIL) scale assessment and US measurements of their upper arm muscles, quadricep muscles, and abdominal wall muscles thickness. We conducted one-month follow-up phone calls to assess for falls, ED revisits, and subsequent hospital visits. RESULTS: We enrolled 43 patients (mean age of 78.5). Ultrasound measurements of the three muscle groups were not significantly different between frail and non-frail groups. Frail participants had greater bicep asymmetry (a difference of 0.47 cm vs 0.24 cm, p < .01). A predictive logistic regression model using average quadriceps thickness and biceps asymmetry was found to identify frail patients (AUC of 0.816). Participants with subsequent falls had smaller quadriceps (1.18 cm smaller, p < .01). Subsequently hospitalized patients were found to have smaller quadriceps muscles (0.54 cm smaller, p = .03) and abdominal wall muscles (0.25 cm smaller, p = .01). CONCLUSION: US measurements of sarcopenia in older patients had mild to moderate associations with frailty, falls and subsequent hospitalizations. Further investigation is needed to confirm these findings.

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients.

BACKGROUND: Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. METHOD: This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. RESULTS: 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). CONCLUSION: A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019.

OBJECTIVES: To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19). METHODS: Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered. RESULTS: Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus. CONCLUSIONS: In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series.

BACKGROUND: Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking. CASE SERIES: In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc.

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism.

BACKGROUND: Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. OBJECTIVES: In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. METHODS: This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality. RESULTS: The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32). CONCLUSION: In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.

Nitrous oxide inhalant abuse and massive pulmonary embolism in COVID-19.

A patient presented to the emergency department with altered mental status and lower extremity weakness in the setting of nitrous oxide inhalant abuse and Coronavirus Disease-2019 (COVID-19) infection. He subsequently developed hypotension and severe hypoxia, found to have a saddle pulmonary embolus (PE) with right heart strain requiring alteplase (tPA).

The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma.

Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.

Ultrasound-Guided Serratus Anterior Plane Block for Intractable Herpes Zoster Pain in the Emergency Department.

BACKGROUND: Herpes zoster (HZV) is a painful vesicular rash that occurs after reactivation in immunosuppressed patients. Analgesia in this patient population has been notoriously difficult. The serratus anterior and erector spinae plane block have both been described as effective thoracic analgesic techniques, but data are limited on their use in HZV. CASE REPORT: A middle-aged man with a history of hypertension and hyperlipidemia presented to the emergency department (ED) with chest and back pain associated with cutaneous rash. Traditional pain regimens were not effective; therefore, a serratus anterior plane block was performed using 25 mL of 0.25% of bupivacaine. The patient's pain decreased from 10 to 2 in 20 min and the patient was discharged without further analgesia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As opiate use decreases in prevalence and utility in the ED, alternatives to analgesia are sought. We describe the technique of regional anesthesia using a serratus anterior plane block as another modality that physicians can use to address HZV-related pain.

Best Practice Recommendations for Point-of-Care Lung Ultrasound in Patients with Suspected COVID-19.

BACKGROUND: Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free. OBJECTIVE: Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety. DISCUSSION: In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS. CONCLUSIONS: Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

Test performance of point-of-care ultrasound for gastric content.

OBJECTIVE: We sought to determine test performance characteristics of emergency physician ultrasound for the identification of gastric contents. METHODS: Subjects were randomized to fast for at least 10 h or to consume food and water. A sonologist blinded to the patient's status performed an ultrasound of the stomach 10 min after randomization and oral intake, if applicable. The sonologist recorded their interpretation of the study using three sonographic windows. Subsequently 2 emergency physicians reviewed images of each study and provided an interpretation of the examination. Test performance characteristics and inter-rater agreement were calculated. RESULTS: 45 gastric ultrasounds were performed. The sonologist had excellent sensitivity (92%; 95% CI 73%-99%) and specificity (85%; 95% CI 62%-92%). Expert review demonstrated excellent sensitivity but lower specificity. Inter-rater agreement was very good (κ = 0.64, 95%CI 0.5-0.78). CONCLUSION: Emergency physician sonologists were sensitive but less specific at detecting stomach contents using gastric ultrasound.

Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath.

OBJECTIVE: The differential diagnoses of patients presenting with chest pain (CP) and shortness of breath (SOB) are broad and non-specific. We aimed to 1) determine how use of point-of-care ultrasound (POCUS) impacted emergency physicians' differential diagnosis, and 2) evaluate the accuracy of POCUS when compared to chest radiograph (CXR) and composite final diagnosis. METHODS: We conducted a prospective observational study in a convenience sample of patients presenting with CP and SOB to the Emergency Department (ED). Treating physicians selected possible diagnoses from a pre-indexed list of possible diagnoses of causes of CP and SOB. The final composite diagnosis from a chart review was determined as the reference standard for the diagnosis. The primary analysis involved calculations of sensitivity and specificity for POCUS identifiable diagnoses in detecting cause of CP and SOB. Additional comparative accuracy analysis with CXRs were conducted. RESULTS: 128 patients with a mean age of 64 ±â€¯17 years were included in the study. Using a reference standard of composite final diagnoses, POCUS had equal or higher specificity to CXR for all indications for which it was used, except for pneumonia. POCUS correctly identified all patients with pneumothorax, pleural effusion and pericardial effusion. In patients with a normal thoracic ultrasound, CXR never provided any actionable clinical information. Adding POCUS to the initial evaluation causes a significant narrowing of the differential diagnoses in which the median differential diagnosis from 5 (IQR 3-6) to 3 (IQR 2-4) p < 0.001. CONCLUSION: In evaluation of patients with CP and SOB, POCUS is a highly feasible diagnostic test which can assist in narrowing down the differential diagnoses. In patients with a normal thoracic ultrasound, the added value of a CXR may be minimal.

Point-of-Care Ultrasound in a Child with Chest Wall Pain and Rib Osteomyelitis.

BACKGROUND: Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. CASE REPORT: A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.

SonoGames: Effect of an Innovative Competitive Game on the Education, Perception, and Use of Point-of-Care Ultrasound.

OBJECTIVES: Gamification is a powerful tool in medical education. SonoGames is a competitive games-based event designed to educate and inspire emergency medicine (EM) residents about point-of-care ultrasound. We sought to describe: (1) the perceived effectiveness of a competitive event on both immediate learning and long-term education; and (2) the resultant attitudes of participants and program directors regarding ultrasound training. METHODS: The SonoGames Organizational Committee designed 2 surveys: 1 for SonoGames V EM resident participants and a second for EM program directors. Survey questions used a 5-point Likert scale to assess overall perceptions and attitudes about ultrasound, changes in self-reported content knowledge and competency, effects on clinical use, and perceived impacts of a competitive game format on education. RESULTS: Seventy-three resident participants and 42 program directors responded to the survey. Ninety-four percent of participants thought that the competitive gaming format of SonoGames was effective in making the event an educational experience. Participants reported that their ultrasound knowledge increased (81%), their enthusiasm for ultrasound increased (87%), and their clinical use of ultrasound increased (61%). Residency program directors reported similar increases to a lesser degree. Greater advancement through the event was associated with more positive responses. Residencies that participated in the event saw greater increases in the use of ultrasound by residents than those that did not. CONCLUSIONS: A competitive games-based educational event focused on point-of-care ultrasound is an effective educational tool. SonoGames increases EM residents' knowledge, enthusiasm, and clinical use of ultrasound both during and after the event.

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.

Carotid Flow Time Changes With Volume Status in Acute Blood Loss.

STUDY OBJECTIVE: Noninvasive predictors of volume responsiveness may improve patient care in the emergency department. Doppler measurements of arterial blood flow have been proposed as a predictor of volume responsiveness. We seek to determine the effect of acute blood loss and a passive leg raise maneuver on corrected carotid artery flow time. METHODS: In a prospective cohort of blood donors, we obtained a Doppler tracing of blood flow through the carotid artery before and after blood loss. Measurements of carotid flow time, cardiac cycle time, and peak blood velocity were obtained in supine position and after a passive leg raise. Measurements of flow time were corrected for pulse rate. RESULTS: Seventy-nine donors were screened for participation; 70 completed the study. Donors had a mean blood loss of 452 mL. Mean corrected carotid artery flow time before blood loss was 320 ms (95% confidence interval [CI] 315 to 325 ms); this decreased after blood loss to 299 ms (95% CI 294 to 304 ms). A passive leg raise had little effect on mean corrected carotid artery flow time before blood loss (mean increase 4 ms; 95% CI -1 to 9 ms), but increased mean corrected carotid artery flow time after blood loss (mean increase 23 ms; 95% CI 18 to 28 ms) to predonation levels. CONCLUSION: Corrected carotid artery flow time decreased after acute blood loss. In the setting of acute hypovolemia, a passive leg raise restored corrected carotid artery flow time to predonation levels. Further investigation of corrected carotid artery flow time as a predictor of volume responsiveness is warranted.

Multi-Institution Validation of an Emergency Ultrasound Image Rating Scale-A Pilot Study.

BACKGROUND: As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design. OBJECTIVE: Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS). METHODS: Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers. RESULTS: Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p < 0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training. CONCLUSION: Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.

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.