Lung ultrasound in a respiratory pandemic.

Australian hospitals have prepared for a major surge in patients due to the infectious respiratory pandemic COVID-19. In other nations, patient presentations have overwhelmed resources. Ultrasound has been shown to be an effective tool to exclude significant life-threats in resource poor settings. In this article, we will describe three lung ultrasound algorithms for the emergency diagnosis of patients presenting with respiratory symptoms during a COVID-19 pandemic: (i) LUSC19: lung ultrasound to assess the severity of COVID-19; (ii) LUSAC: lung ultrasound to exclude alternative causes of respiratory distress; and (iii) LUSI: lung ultrasound following intubation. We anticipate that emergency physicians will use these algorithms during the upcoming respiratory pandemic to rapidly determine the severity of COVID-19 infection, to seek and treat significant alternative diagnoses and ensure endotracheal intubation.

Should we ditch the supine chest X ray in early trauma assessment?

The supine chest X ray is a standard part of early trauma assessment protocols. It is used to rapidly identify potentially life threatening chest injuries. However, latest research shows that chest ultrasound has superior accuracy when compared to supine chest X ray for diagnosing most chest injuries. Is it time we allowed ultrasound to supersede supine chest X ray as the initial investigative modality of choice for the patient with thoracic trauma?

Bedside cardiac ultrasound training should be mandated in the emergency department.

BACKGROUND: Bedside cardiac ultrasound can be performed quickly and accurately in the emergency department to diagnose and treat cardiovascular causes of patient deterioration. In Australian emergency departments, it is an underutilised tool. This may be because becoming proficient at performing bedside cardiac ultrasound is not mandated by the Australasian College for Emergency Medicine. CASES: Case 1: A 45-year-old male presented with hypoxia and shock and head injury. Findings consistent with pulmonary embolism on bedside cardiac ultrasound prompted rapid treatment with thrombolysis. The patient survived to hospital discharge.Case 2: A 54-year-old female presented with chest pain. Her bedside cardiac ultrasound revealed a dilated proximal aorta and a dissection flap in the abdominal aorta enabling investigations and operative management to be expedited.Case 3: A 21-year-old male presented with features of lower respiratory tract infection. Chest X-ray revealed a large heart and consolidation. Bedside cardiac ultrasound demonstrated severe dilated cardiomyopathy and prompted the patient's admission into the coronary care unit. CONCLUSION: Evidence shows that emergency doctors can perform bedside cardiac ultrasound accurately after minimal training. It increases the accuracy of diagnosis. Training in this vital diagnostic tool should be mandated for emergency medicine trainees in Australia.

Use of ultrasound for non-trauma patients in the emergency department.

OBJECTIVE: In the past decade, there has been substantial knowledge translation in the use of ultrasound (US) by critical care physicians to aid diagnosis of the non-trauma patient. This study aimed to determine emergency doctors' level of training in ultrasonography, pattern of US use in regular practice and barriers to US use for the non-trauma patient presenting to an emergency department. METHOD: A survey on the use of US in non-trauma patients was conducted, targeting all emergency physicians and emergency medicine trainees in a single adult tertiary referral centre. RESULTS: The response rate was 92.7% with 38 completed surveys analysed. A course in non-trauma US had been completed by 58% of respondents. The most common non-trauma formal US training was in vascular access (82%, 95% confidence interval [CI] 66.8-90.6), detection of abdominal aortic aneurysm (79%, 95% CI 63.7-88.9) and pericardial fluid (84%, 95% CI 69.6-92.6). Upon completion of formal training, US was used significantly more frequently for obtaining vascular access (odds ratio [OR] 12.0), detection of abdominal aortic aneurysms (OR 4.3) and detection of pericardial fluid (OR 15.5). Most doctors felt the greatest barriers to the use of US in the non-trauma patient were the lack of teaching, confidence in findings, experienced supervisors and time. CONCLUSIONS: Among ED personnel, use of US to diagnose several non-traumatic conditions was low, but specific training was associated with significantly more US use. Increased training and availability of US-experienced supervisors might further improve utility of this important adjunct to the practice of emergency medicine.

B-type natriuretic peptide testing and the accuracy of heart failure diagnosis in the emergency department.

BACKGROUND: It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. METHODS AND RESULTS: Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. CONCLUSIONS: In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00163709.

B-type natriuretic peptide testing, clinical outcomes, and health services use in emergency department patients with dyspnea: a randomized trial.

BACKGROUND: B-type natriuretic peptide (BNP) is used to diagnose heart failure, but the effects of using the test on all dyspneic patients is uncertain. OBJECTIVE: To assess whether BNP testing alters clinical outcomes and health services use of acutely dyspneic patients. DESIGN: Randomized, single-blind study. Patients were assigned to a treatment group through randomized numbers in a sealed envelope. Patients were blinded to the intervention, but clinicians and those who assessed trial outcomes were not. SETTING: 2 Australian teaching hospital emergency departments. PATIENTS: 612 consecutive patients who presented with acute severe dyspnea from August 2005 to March 2007. INTERVENTION: BNP testing (n = 306) or no testing (n = 306). MEASUREMENTS: Admission rates, length of stay, and emergency department medications (primary outcomes); mortality and readmission rates (secondary outcomes). RESULTS: There were no between-group differences in hospital admission rates (85.6% [BNP group] vs. 86.6% [control group]; difference, -1.0 percentage point [95% CI, -6.5 to 4.5 percentage points]; P = 0.73), length of admission (median, 4.4 days [interquartile range, 2 to 9 days] vs. 5.0 days [interquartile range, 2 to 9 days]; P = 0.94), or management of patients in the emergency department. Test discrimination was good (area under the receiver-operating characteristic curve, 0.87 [CI, 0.83 to 0.91]). Adverse events were not measured. LIMITATION: Most patients were very short of breath and required hospitalization; the findings might not apply for evaluating patients with milder degrees of breathlessness. CONCLUSION: Measurement of BNP in all emergency department patients with severe shortness of breath had no apparent effects on clinical outcomes or use of health services. The findings do not support routine use of BNP testing in all severely dyspneic patients in the emergency department. PRIMARY FUNDING SOURCE: Janssen-Cilag.