From compression to diagnosis: identification of superior vena cava syndrome using point-of-care ultrasound in the emergency department.

BACKGROUND: Superior vena cava (SVC) syndrome is an urgent condition arising from restricted blood flow through the SVC, often linked to factors like malignancy, thrombosis, or infections. Typically, confirmation of the diagnosis involves computed tomography. However, many patients experience respiratory distress and cannot lie supine. Given the increasing integration of point-of-care ultrasound in emergency medicine, it is important to be familiar with findings that are suggestive of this important condition. CASE REPORT: In this case report, we highlight a young patient presenting to the emergency department with superior vena cava syndrome symptoms, successfully diagnosed using point-of-care ultrasound. CONCLUSION: This case highlights the utility of point-of-care ultrasound based diagnosis of SVC syndrome and upper arm deep venous thrombosis in a patient with underlying malignancy which ultimately led to early involvement of relevant speciality for initiation of treatment.

Exploring Eye-tracking Technology as an Assessment Tool for Point-of-care Ultrasound Training.

OBJECTIVES: Eye-tracking technology has emerged as a potentially useful learner assessment tool in several medical specialties. In the fields of general surgery and anesthesiology, it has been shown to reliably differentiate between different levels of expertise in procedural skills. In the field of radiology, it has been shown to be a valid assessment tool for diagnostic test interpretation. Current methods of competency assessment in point-of-care ultrasound (POCUS) remain a challenge, because they require significant direct observation time by an instructor. The purpose of this study was to determine if eye-tracking technology can accurately distinguish between novice and experts in the interpretation of POCUS clips, specifically of the focused assessment using sonography in trauma (FAST) scan. METHODS: A convenience sample of medical students, residents, and emergency physicians from a single academic emergency department were invited to participate. Participants included both novices and experts in POCUS. Each participant completed a baseline questionnaire and viewed 16 video clips of a FAST ultrasound examination while their gaze patterns were recorded by a commercially available eye-tracking device. The primary outcome was total gaze time on the area of interest (AOI). Secondary outcomes included total time to fixation, mean number of fixations, and mean duration of first fixation on the AOI. RESULTS: Fifteen novices and 15 experts completed this study. For total gaze time on the AOI, experts fixated their gaze significantly longer than novices (75.8 ± 16.2 seconds vs. 56.6 ± 12.8 seconds, p = 0.001). Similarly, experts were significantly faster to fixate on the AOI and had a higher fixation count on the AOI (8.5 ± 4.0 seconds vs. 15.1 ± 6.8 seconds, p = 0.003; and 170 ± 30 vs. 143 ± 28 seconds, p = 0.016). There were no differences on the mean duration of first fixation on the AOI (0.42 ± 0.12 seconds vs. 0.39 ± 0.09 seconds, p = 0.467). CONCLUSION: Eye-tracking technology shows the potential to differentiate between experts and novices by their gaze patterns on video clips of FAST examinations. The total gaze time on the AOI may be a useful metric to help in the assessment of competency in POCUS image interpretation. In addition, the evaluation of gaze patterns may help educators identify causes of interpretation errors. Future studies are needed to further validate these metrics in a larger cohort.

Left ventricular outflow tract pseudoaneurysm diagnosed with point-of-care ultrasound in the emergency department.

Left ventricular outflow tract pseudoaneurysms are a rare but life-threatening disorder, often caused by complications of cardiac surgery or myocardial infarction. We present a case report of a patient with no prior risk factors who presented with a six-month history of progressive exertional dyspnea, bilateral leg swelling and cough. Point-of-care ultrasound revealed an unexpected outpouching of the left ventricle. He was diagnosed with a left ventricular outflow tract pseudoaneurysm and subsequently went into cardiogenic shock secondary to extension of pseudoaneurysm causing extrinsic compression of the coronary arteries. The patient underwent successful emergency surgical repair and made a full recovery.

Comparison of techniques for visualisation of the airway anatomy for ultrasound-assisted intubation: A prospective study of emergency department patients.

PURPOSE: Ultrasound has been shown to be a highly accurate adjunct for confirming endotracheal tube (ETT) placement, however there is no universally accepted scanning technique. The objective of this study was to determine which ultrasound technique provides the highest rate of adequate airway visualisation in a sample of stable emergency department (ED) patients. METHODS: We conducted a prospective observational study using a convenience sample of ED patients. Airway imaging was performed using the following five techniques: 1) transcricothryoid membrane (TCM), 2) suprasternal notch (SSN) without transducer pressure, 3) SSN with pressure, 4) SSN with pressure to the left of the trachea and 5) SSN with pressure to the right of the trachea. A blinded reviewer scored the adequacy of airway visualisation for each technique. RESULTS: A total of 100 patients were enrolled in the study. SSN to the left of the trachea with pressure had the highest rate of adequate airway visualisation (93.0%, 95% CI 86.1-97.1%), followed by 82.0% (95% CI 73.1-89.0%) for SSN with pressure, 74.0% (95% CI 64.3-82.3%) for TCM, 44.0% (95% CI 34.1-54.3%) for SSN without pressure, and 1.0% (95% CI 0.0-5.4%) for SSN to the right of the trachea. In 76.0% (95% CI 66.4-84.0%) of patients, the SSN view was improved by moving the probe off the midline towards the patient's left. CONCLUSIONS: In a sample of ED patients, the airway anatomy relevant for use in endotracheal intubation is best visualised at the SSN to the left of the trachea with transducer pressure applied.

Diagnosis of a Strangulated Laparoscopic Incisional Hernia with Point-of-Care Ultrasonography.

The use of point-of-care ultrasound for the diagnosis of bowel obstructions and hernias is becoming increasingly common in the emergency department (ED). Using a relatively rare case of an incisional port hernia, we demonstrate the ultrasound findings of a strangulated hernia causing a partial small bowel obstruction. A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements. There was a palpable mass in the left lower quadrant under the 12mm trocar port incision. ED point-of-care ultrasound revealed herniated akinetic loops of bowel through her laparoscopy incision. This is the first case report to describe the use of point-of-care ultrasound for the diagnosis of a strangulated incisional port hernia at the bedside.

Predictive value of the Ontario prehospital stroke screening tool for the identification of patients with acute stroke.

BACKGROUND: In 2005, a prehospital stroke screening tool was implemented in Toronto, Ontario, Canada. Patients identified by paramedics through the use of this tool in the field were transported to a regional stroke center under an acute stroke protocol. OBJECTIVE: To determine the positive predictive value (PPV) of the Ontario Prehospital Stroke Screening Tool for identification of acute stroke at a single stroke center. METHODS: We conducted a retrospective analysis of consecutive patients transported to a regional stroke center under the prehospital acute stroke protocol over a 12-month period. Final diagnoses, treatments, and outcomes were abstracted from a provincial registry. Rates of fibrinolysis were compared with those for the 12-month period prior to implementation of the stroke protocol. RESULTS: Three hundred twenty-five patients were triaged under the emergency medical services (EMS) acute stroke protocol over the study period. The PPV of the screening tool was 89.5% (95% confidence interval [CI]: 85.7-92.7%) for acute stroke. Thirty-four patients (11%) had nonstroke conditions, with the most common being seizure (4%). The rate of administration of tissue plasminogen activator (tPA) for all patients with suspected stroke increased from 5.9% to 10.1% (p = 0.04) compared with the rate in the 12-month period prior to implementation of the acute stroke protocol. The tPA rate for patients arriving under the stroke protocol was 17.2%. Most patients (75%) receiving tPA arrived from outside the hospital catchment area. CONCLUSIONS: In this preliminary study, the Ontario Prehospital Stroke Screening Tool had a high PPV for acute stroke and appeared to be effective for identifying patients who required triage to a single regional stroke center. Following implementation of a citywide acute stroke protocol using this screening tool, we observed an increase in the number of patients who were eligible for and received fibrinolysis at our stroke center.

Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training.

OBJECTIVES: Web-based learning has several potential advantages over lectures, such as anytime-anywhere access, rich multimedia, and nonlinear navigation. While known to be an effective method for learning facts, few studies have examined the effectiveness of Web-based formats for learning procedural skills. The authors sought to determine whether a Web-based tutorial is at least as effective as a didactic lecture for learning ultrasound-guided vascular access (UGVA). METHODS: Participating staff emergency physicians (EPs) and junior emergency medicine (EM) residents with no UGVA experience completed a precourse test and were randomized to either a Web-based or a didactic group. The Web-based group was instructed to use an online tutorial and the didactic group attended a lecture. Participants then practiced on simulators and live models without any further instruction. Following a rest period, participants completed a four-station objective structured clinical examination (OSCE), a written examination, and a postcourse questionnaire. Examination results were compared using a noninferiority data analysis with a 10% margin of difference. RESULTS: Twenty-one residents and EPs participated in the study. There were no significant differences in mean OSCE scores (absolute difference = -2.8%; 95% confidence interval [CI] = -9.3% to 3.8%) or written test scores (absolute difference = -1.4%; 95% CI = -7.8% to 5.0%) between the Web group and the didactic group. Both groups demonstrated similar improvements in written test scores (26.1% vs. 25.8%; p = 0.95). Ninety-one percent (10/11) of the Web group and 80% (8/10) of the didactic group participants found the teaching format to be effective (p = 0.59). CONCLUSIONS: Our Web-based tutorial was at least as effective as a traditional didactic lecture for teaching the knowledge and skills essential for UGVA. Participants expressed high satisfaction with this teaching technology. Web-based teaching may be a useful alternative to didactic teaching for learning procedural skills.

Early failures with a spheric interposition arthroplasty of the thumb basal joint.

PURPOSE: The purpose of this study is to report the early results with the Orthosphere (Wright Medical Technology Inc, Arlington, TN) spheric interpositional arthroplasty. METHODS: Six women and 1 man had Orthosphere arthroplasty between 2000 and 2001. The mean age at the time of surgery was 52 years (range, 24-73 years) and the mean duration of clinical and radiographic follow-up evaluation was 33 months (range, 29-44 months). RESULTS: Six of 7 Orthosphere implants subsided into the trapezium resulting in pain, weakness, and stiffness. There was 1 implant dislocation. Five patients have had revision surgery to trapezial excision ligament reconstruction and tendon interposition arthroplasty. Of the remaining 2 patients 1 is contemplating presently revision surgery and the other is experiencing mild residual pain. No patients were satisfied completely with their Orthosphere results. CONCLUSIONS: In our experience the early outcome of the Orthosphere interpositional arthroplasty has been unacceptable. We no longer use the device at our institutions.