Comparison of Commonly Carried Liquids Against Commercial Ultrasound Gel for Use in the Backcountry Setting.

INTRODUCTION: Point-of-care ultrasound (POCUS) is utilized in austere environments because it is lightweight, durable, battery powered, and portable. In austere settings, weight and space constraints are limitations to carrying dedicated ultrasound gel. Few studies have assessed commonly carried liquids as gel alternatives. The study objective was to assess the suitability of common food and personal care products as ultrasound coupling agents compared with that of commercial gel. METHODS: A noninferiority study compared 9 products to commercial gel. Each substance was independently tested on 2 subjects by 2 sonographers covering 8 standardized ultrasound windows. Clips were recorded, blinded, and independently graded by 2 ultrasound fellowship-trained physicians on the ability to make clinical decisions and technical details, including contrast, resolution, and artifact. A 20% noninferiority margin was set, which correlates to levels considered to be of reliably sufficient quality by American College of Emergency Physicians' guidelines. The substances included water, soap, shampoo, olive oil, energy gel, maple syrup, hand sanitizer, sunscreen, and lotion. RESULTS: A total of 300 of 318 (94%) clips met the primary endpoint of adequacy to make a clinical decision. All media, except sunscreen, were noninferior to commercial gel in the ability to make a clinical decision (α=0.05). In terms of secondary outcomes, resolution, artifact, and contrast, all substances were noninferior to commercial gel (α=0.05). The sonographers concluded that all gel alternatives' usability performed similarly to commercial gel, with the exception of energy gel. CONCLUSIONS: Of the 9 substances tested, 8 were noninferior to commercial gels for clinical decisions. Our study indicates that several POCUS gel substitutes are serviceable to produce clinically adequate images.

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy.

BACKGROUND: Recent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest. OBJECTVES: We sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support. METHODS: This was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs). RESULTS: We obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7-14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5-13.5 s) compared with SX (9.3 s, IQR 6.7-15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging. CONCLUSIONS: Echo was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Point of Care Ultrasound Use by Associate Providers for Differentiating Abscess Versus Cellulitis Skin and Soft Tissue Infection in the Emergency Department.

BACKGROUND: Skin and soft tissue infections (SSTIs) are a common complaint in the ambulatory setting and pose a significant burden on the health care system. OBJECTIVES: We sought to determine the accuracy of ultrasound for detecting soft tissue abscesses by emergency medicine associate providers (APs). METHODS: This was a prospective observational study of adult patients with suspected SSTI in the emergency department of a rural tertiary care academic medical center. The AP performed and interpreted point-of-care ultrasound (POCUS) of the suspected infected area. Ultrasound images and interpretation were reviewed by the attending emergency physician with either rejection or agreement of the image interpretation, diagnosis, and management. If incision and drainage was performed, presence or absence of purulent drainage was recorded. RESULTS: Sixty-four patients with suspected SSTI were enrolled: 29 had POCUS-proven abscesses and 33 had cellulitis; 2 were excluded. AP clinical evaluation alone for identifying abscess revealed sensitivity of 92.3 (74.9-99.1), specificity of 67.7 (49.5-82.6), positive predictive value of 68.6 (57.0-78.2), and negative predictive value of 92.0 (81.4-100). The use of POCUS by APs in addition to clinical examination demonstrated sensitivity of 96.2 (80.4-99.9), specificity of 93.9 (79.8-99.3), positive predictive value of 92.6 (76.5-98.0), and negative predictive value of 96.9 (81.9-99.5). p values were <0.05 for test characteristics. Ultrasound results changed SSTI management decisions in 10 of 62 (16.1%) patients, with the most common change being a new incision and drainage or needle aspiration. Agreement of the POCUS interpretation between APs and attending physicians was 96.8% with a κ of 0.94 (0.85-1.00). CONCLUSION: With modest training, APs can successfully use POCUS to identify abscesses in patients in the emergency department with SSTIs. POCUS increases the ability to rule in the diagnosis and changes management in a clinically relevant number of patients with SSTIs.

Systematic Review: The Role of Intravenous and Oral Contrast in the Computed Tomography Evaluation of Acute Appendicitis.

BACKGROUND: This systematic review provides practicing emergency physicians updated information regarding the role of oral and intravenous contrast in the computed tomography (CT) evaluation of acute appendicitis. METHODS: A PubMed literature search was conducted from January 1, 1996 to December 31, 2018 and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review. RESULTS: Fifty-seven articles met criteria for rigorous review, of which 14 were appropriate for citation in this review. Excellent evidence shows that oral contrast does not improve the test characteristics of CT with intravenous contrast (IVCT) in the evaluation of adults suspected of having acute appendicitis. Good evidence shows that noncontrast abdominal CTs have excellent test characteristics for this same group of patients. CONCLUSIONS: Considering its downsides and lack of utility, the medical literature does not support using oral contrast in the evaluation of acute appendicitis. There is no direct evidence showing that IVCT is better than a noncontrast CT in the evaluation of acute appendicitis; however, the available literature is consistent with slightly better test characteristics for IVCTs. Still, if IVCT cannot be obtained in a timely manner, noncontrast CTs are extremely accurate in detecting this disease.

Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age.

OBJECTIVES: To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN: This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS: We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS: POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.

Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department.

BACKGROUND: This review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis. METHODS: A PubMed literature search was conducted for articles published between January 1, 1996 and May 31, 2017 and limited to human clinical trials written in English with relevant keywords. High-quality studies identified then underwent a structured review. Recommendations herein are made based on the literature review. RESULTS: Two hundred seventy-two abstracts fulfilling the search criteria were screened and 10 appropriate articles were rigorously reviewed in detail. There were 8 prospective studies and 2 retrospective studies. Only 1 of them was a multi-institutional randomized trial. POCUS performed in the emergency department (ED) is moderately sensitive and specific in making the diagnosis of urolithiasis in symptomatic patients. Suspected urolithiasis patients evaluated initially with ED POCUS have complication rates compatible with those evaluated initially with computed tomography. CONCLUSIONS: POCUS has moderate accuracy in making the diagnosis of urolithiasis. Nevertheless, it may be safely used as a first line of imaging in ED patients with suspected symptomatic urolithiaisis.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience.

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Creation of a High-fidelity, Low-cost Pediatric Skull Fracture Ultrasound Phantom.

Over the past decade, point-of-care ultrasound has become a common tool used for both procedures and diagnosis. Developing high-fidelity phantoms is critical for training in new and novel point-of-care ultrasound applications. Detecting skull fractures on ultrasound imaging in the younger-than-2-year-old patient is an emerging area of point-of-care ultrasound research. Identifying a skull fracture on ultrasound imaging in this age group requires knowledge of the appearance and location of sutures to distinguish them from fractures. There are currently no commercially available pediatric skull fracture models. We outline a novel approach to building a cost-effective, simple, high-fidelity pediatric skull fracture phantom to meet a unique training requirement.

Role of inferior vena cava diameter in assessment of volume status: a meta-analysis.

BACKGROUND AND OBJECTIVE: Hypovolemic shock is an important cause of death in the emergency department (ED). We sought to conduct a meta-analysis to quantify existing evidence on sonographic measurement of inferior vena cava (IVC) diameter in assessing of volume status adult ED patients. METHODS: A search of 5 major databases of biomedical publication, EMBASE, Ovid Medline, evidence-based medicine (EBM) Reviews, Scopus, and Web of Knowledge, was performed in first week of March 2011. Studies meeting the following criteria were included: (1) prospectively conducted, (2) measured IVC diameter using ultrasonography, (3) inpatients under spontaneous ventilation, and (4) reported IVC diameter measurement with volume status or shock. Article search, study quality assessment, and data extraction were done independently and in duplicate. Mean difference in IVC diameter was calculated using RevMan version 5.5 (Cochrane collaboration). RESULTS: A total of 5 studies qualified for study eligibility from 4 different countries, 3 being case-control and 2 before-and-after design, studying 86 cases and 189 controls. Maximal IVC diameter was significantly lower in hypovolemic status compared with euvolemic status; mean difference (95% confidence interval) was 6.3 mm (6.0-6.5 mm). None of the studies blinded interpreters for volume status of participants. CONCLUSION: Moderate level of evidence suggests that the IVC diameter is consistently low in hypovolemic status when compared with euvolemic. Further blinded studies are needed before it could be used in the ED with confidence.