A Novel Three-Dimensional-Printed Ultrasound-Guided Hip Arthrocentesis Model.

When evaluating patients with hip pain, clinicians may be trained to both evaluate for a hip effusion and perform ultrasound-guided arthrocentesis to evaluate the etiology of the effusion. We present a novel 3-dimensional-printed hip arthrocentesis model, which can be used to train clinicians to perform both tasks under ultrasound guidance. Our model uses a combination of a 3-dimensional-printed hip joint, as well as readily available materials such as an infant Ambu (Ballerup, Denmark) bag, syringe, intravenous line kit, and silicone. We present our experience so that others may use and adapt our model for their training purposes.

Effect of insonation angle on peak systolic velocity variation.

OBJECTIVES: As point of care ultrasound (POCUS) has become more integrated into emergency and critical care medicine, there has been increased interest in utilizing ultrasound to assess volume status. However, recent studies of carotid POCUS on volume status and fluid responsiveness fail to recognize the effect insonation angle has on their results. To address this, we studied the effect of insonation angle on peak systolic velocity (PSV) change associated with respiratory variation (RV) and passive leg raise (PLR). METHODS: Doppler measurements were obtained from 51 subjects presenting to the ED. Minimal and maximal PSV were obtained using insonation angles of 46°, 60°, and 90°. ∆PSV was calculated using PLR and RV as trial methods. Results were categorized into two groups, those with a ∆PSV > 10% and those with a ∆PSV ≤ 10%. ∆PSV mean and standard error, as well as measures of agreement were calculated. RESULTS: Mean ∆PSV associated with PLR test was 9% in the 46° and 60° groups, and 18% in the 90° group, with standard errors of 6, 7, and 14%, respectively. Using 46° as our relative gold standard, Kappa was 0.23 at 60° and 0.11 at 90° with RV as the trial method, and 0.23 at 60° and 0.01 at 90° with a PLR as the trial method. CONCLUSIONS: Variation in PSV is heavily dependent on insonation angle. There was only slight to fair agreement in ∆PSV among the various insonation angles. Further investigation of the optimal insonation angle to assess ∆PSV should be undertaken.

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.

Utilizing left ventricular outflow tract velocity changes to predict fluid responsiveness in septic patients: a case report.

Toxin-mediated vasodilation in the sepsis syndrome can lead to end-organ dysfunction and shock. Assessing for fluid responsiveness and preload optimization with intravenous fluids is a central tenet in the management of sepsis. Aggressive fluid administration can lead to pulmonary edema and heart failure, whereas premature inotropic or vasopressor support can worsen organ perfusion. Inferior vena cava ultrasonography is commonly used to assess for fluid responsiveness but has multiple limitations.

Pelvic ultrasonography and length of stay in the ED: an observational study.

OBJECTIVES: We compared emergency physician-performed pelvic ultrasonography (EPPU) with radiology department-performed pelvic ultrasonography (RPPU) in emergency department (ED) female patients requiring pelvic ultrasonography and their outcomes in relation to ED length of stay, ED readmission, and alternative diagnosis, within a 14-day follow-up period. METHODS: This was a prospective, observational study of female patients of reproductive age who required either an EPPU or RPPU for their ED evaluation. We hypothesized that patients receiving EPPU would have a length of stay reduction greater than or equal to 60 minutes, as compared with RPPU. Statistical analyses included an independent-samples t test and multivariate regression modeling to control for factors associated with ED LOS. RESULTS: Eighteen resident physicians performed EPPU, with 15 attending physicians supervising. Forty-eight patients received only EPPU, and 84 patients received only RPPU. In univariate analysis, those who received EPPU had an ED LOS 162 minutes less than those who received RPPU (95% confidence interval, 106-209 minutes). In multivariate analysis controlling for gynecologist consultation, disposition, and pregnancy status, patients who received EPPU had an ED LOS reduction of 108 minutes when compared with RPPU (95% confidence interval, 38-166 minutes). Five patients (10%) who had received EPPU and were discharged from the ED returned to the ED within 2 weeks, but none had alternative diagnoses. CONCLUSIONS: Patients with EPPU had statistically and clinically significant reductions in ED LOS, even when controlling for disposition, gynecologist consultation in the ED, and pregnancy status. No patients in the study had an alternative diagnosis within 2 weeks of EPPU.

Using tele-ultrasound to teach medical students: A randomised control equivalence study.

Objectives: Undergraduate ultrasound education is becoming increasingly important, but its expansion is limited by time, space and the availability of trained faculty. In order to validate an alternative and more accessible teaching model, our aim was to assess whether combining teleguidance and peer-assisted learning to teach ultrasound is as effective as traditional in-person methods. Methods: Peer instructors taught 47 second-year medical students ocular ultrasound via either teleguidance or traditional in-person methods. Proficiency was assessed using a multiple-choice knowledge test and objective structured clinical examination (OSCE). Confidence, overall experience, and experience with a peer instructor were measured using a 5-point Likert scale. Two one-sided t-tests were used to measure equivalency between the two groups. The null hypothesis that the two groups were not different was rejected when P < 0.05. Results: The teleguidance group performed as well as the traditional in-person group in terms of knowledge change, confidence change, OSCE time and OSCE score (p = 0.011, p = 0.006, p = 0.005 and  = 0.004, respectively, indicating the two groups are statistically equivalent). The teleguidance group rated the experience highly overall (4.06/5), but less than the traditional group (4.47/5; P = 0.448, indicating statistical difference). Peer instruction was rated 4.35/5 overall. Conclusion: Peer-instructed teleguidance was equivalent to in-person instruction with respect to knowledge change, confidence gain and OSCE performance in basic ocular ultrasound.

Pseudoaneurysm of the Dorsalis Pedis Artery Diagnosed on Point-of-Care Ultrasound.

A 46-year-old man presented with a painless mass on his dorsal right foot one week after striking it on a door. A traumatic hematoma was suspected, and needle aspiration of the mass is considered. However, point-of-care ultrasound performed by the emergency physician identified a pseudoaneurysm of the dorsalis pedis artery, a rare condition that can occur after minor trauma or iatrogenic intervention. This report demonstrates how point-of-care ultrasound can be used to identify a pseudoaneurysm of the lower extremity, thereby expediting emergency department workup and preventing potentially dangerous diagnostic procedures.

Feasibility of patient-performed lung ultrasound self-exams (Patient-PLUS) as a potential approach to telemedicine in heart failure.

AIMS: Patient-performed lung ultrasound (LUS) in a heart failure (HF) telemedicine model may be used to monitor worsening pulmonary oedema and to titrate therapy, potentially reducing HF admission. The aim of the study was to assess the feasibility of training HF patients to perform a LUS self-exam in a telemedicine model. METHODS AND RESULTS: A pilot study was conducted at a public hospital involving subjects with a history of HF. After a 15 min training session involving a tutorial video, subjects performed a four-zone LUS using a handheld ultrasound. Exams were saved on a remote server and independently reviewed by two LUS experts. Studies were determined interpretable according to a strict definition: the presence of an intercostal space, and the presence of A-lines, B-lines, or both. Subjects also answered a questionnaire to gather feedback and assess self-efficacy. The median age of 44 subjects was 53 years (range, 36-64). Thirty (68%) were male. Last educational level attained was high school or below for 31 subjects (70%), and one-third used Spanish as their preferred language. One hundred fifty of 175 lung zones (85%) were interpretable, with expert agreement of 87% and a kappa of 0.49. 98% of subjects reported that they could perform this LUS self-exam at home. CONCLUSIONS: This pilot study reports that training HF patients to perform a LUS self-exam is feasible, with reported high self-efficacy. This supports further investigation into a telemedicine model using LUS to reduce emergency department visits and hospitalizations associated with HF.

Role of Ultrasound in the Identification of Longitudinal Axis in Soft-Tissue Foreign Body Extraction.

Identification and retrieval of soft-tissue foreign bodies (STFB) poses significant challenges in the emergency department. Prior studies have demonstrated the utility of ultrasound (US) in identification and retrieval of STFBs, including radiolucent objects such as wood. We present a case of STFB extraction that uses US to identify the longitudinal axis of the object. With the longitudinal axis identified, the foreign body can be excised by making an incision where the foreign body is closest to the skin. The importance of this technique as it pertains to minimizing surrounding tissue destruction and discomfort for patients has not been previously reported.

Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome.

OBJECTIVES: The goal of this study was to examine the ability of emergency physicians who are not experts in emergency ultrasound (US) to perform lung ultrasonography and to identify B-lines. The hypothesis was that novice sonographers are able to perform lung US and identify B-lines after a brief intervention. In addition, the authors examined the diagnostic accuracy of B-lines in undifferentiated dyspneic patients for the diagnosis of acute heart failure syndrome (AHFS), using an eight-lung-zone technique as well as an abbreviated two-lung-zone technique. METHODS: This was a prospective, cross-sectional study of patients who presented to the emergency department (ED) with acute dyspnea from May 2009 to June 2010. Emergency medicine (EM) resident physicians, who received a 30-minute training course in thoracic US examinations, performed lung ultrasonography on patients presenting to the ED with undifferentiated dyspnea. They attempted to identify the presence or absence of sonographic B-lines in eight lung fields based on their bedside US examinations. An emergency US expert blinded to the diagnosis and patient presentation, as well as to the residents' interpretations of presence of B-lines, served as the criterion standard. A secondary outcome determined the accuracy of B-lines, using both an eight-lung-zone and a two-lung-zone technique, for predicting pulmonary edema from AHFS in patients presenting with undifferentiated dyspnea. Two expert reviewers who were blinded to the US results determined the clinical diagnosis of AHFS. RESULTS: A cohort of 66 EM resident physicians performed lung US on 380 patients with a range of 1 to 28 examinations, a mean of 5.8 examinations, and a median of three examinations performed per resident. Compared to expert interpretation, lung US to detect B-lines by inexperienced sonographers achieved the following test characteristics: sensitivity 85%, specificity 84%, positive likelihood ratio (+LR) 5.2, negative likelihood ratio (-LR) 0.2, positive predictive value (PPV) 64%, and negative predictive value (NPV) 94%. Regarding the secondary outcome, the final diagnosis was AHFS in 35% of patients (134 of 380). For novice sonographers, one positive lung zone (i.e., anything positive) had a sensitivity of 87%, a specificity of 49%, a +LR of 1.7, a -LR of 0.3, a PPV of 50%, and an NPV of 88% for predicting AHFS. When all eight lung zones were determined positive (i.e., totally positive) by novice sonographers, the sensitivity was 19%, specificity was 97%, +LR was 5.7, -LR was 0.8, PPV was 76%, and NPV was 68% for predicting AHFS. The areas under the curve for novice and expert sonographers were 0.77 (95% CI = 0.72 to 0.82) and 0.76 (95% CI = 0.71 to 0.82), respectively. CONCLUSIONS: Novice sonographers can identify sonographic B-lines with similar accuracy compared to an expert sonographer. Lung US has fair predictive value for pulmonary edema from acute heart failure in the hands of both novice and expert sonographers.