Successful use of intra-arrest thrombolysis for electrical storm due to acute myocardial infarction.

Acute vascular thrombotic disease, including acute myocardial infarction and pulmonary embolism, accounts for 70% of sudden outpatient cardiac arrest. The role of intra-arrest thrombolytic administration aimed at reversing the underlying cause of cardiac arrest remains an area of debate with recent guidelines advising against routine use. We present a case of prolonged refractory ventricular fibrillation electrical storm in a patient who demonstrated intra-arrest electrocardiographic and sonographic markers confirming acute myocardial infarction. Return of spontaneous circulation was rapidly achieved after rescue intra-arrest bolus thrombolysis.Highlights of this case are discussed in the context of the current evidence for thrombolytic therapy in cardiac arrest with specific attention to the issue of patient selection.

Emergency clinician-performed compression ultrasonography for deep venous thrombosis of the lower extremity.

STUDY OBJECTIVE: Emergency clinician-performed ultrasonography holds promise as a rapid and accurate method to diagnose and exclude deep venous thrombosis. However, the diagnostic accuracy of emergency clinician-performed ultrasonography performed by a heterogenous group of clinicians remains undefined. METHODS: Prospective, single-center study conducted at an urban, academic emergency department (ED). Clinician participants included ED faculty, supervised residents, and midlevel providers who completed a training course for above-calf, 3-point-compression, venous ultrasonography. Patient participants had suspected leg deep venous thrombosis and greater than or equal to 1 predefined sign or symptom. Before any imaging, clinicians classified patients as low (<15%), moderate (15% to 40%), or high (>40%) pretest probability of deep venous thrombosis, followed by emergency clinician-performed ultrasonography. A whole-leg reference venous ultrasonography was then performed and interpreted separately in the radiology department. Patients were followed for 30 days. The criterion standard for deep venous thrombosis(+), required thrombosis of any leg vein on a reference ultrasonograph and clinical plan to treat. RESULTS: We enrolled 183 patients, and 27 (15%) had deep venous thrombosis(+). The sensitivity and specificity emergency clinician-performed ultrasonography was 70% (95% confidence interval [CI] 60% to 80%) and 89% (95% CI 83% to 94%), respectively, with overall diagnostic accuracy of 85% (95% CI 79% to 90%). The posterior probability of deep venous thrombosis(+) among the 88 low-risk patients with a negative emergency clinician-performed ultrasonographic result was 1 of 88, or 1.1% (95% CI 0% to 6%), and the posterior probability of deep venous thrombosis(+) among 14 high-risk patients with a positive emergency clinician-performed ultrasonographic result was 11 of 14, or 79% (95% CI 49% to 95%). CONCLUSION: The overall diagnostic accuracy of single-visit emergency clinician-performed ultrasonography performed by a heterogeneous group of ED clinicians is intermediate but may be improved by pretest probability assessment.

ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain.

INTRODUCTION: We hypothesized that emergency physician-performed endovaginal ultrasound (EVUS) would change diagnostic decision making in nonpregnant women with right lower quadrant (RLQ) pain. METHODS: A prospective cohort of female patients was enrolled at an urban emergency department (ED). Inclusion criteria were RLQ pain, hemodynamic stability, and a strong suspicion for appendicitis or right adnexal pathology. Treating physicians were queried regarding pre- and post-ED EVUS probability of disease, differential diagnoses, consultation, and management. Positive findings included large cysts or multitissue densities, tubal dilation, uterine enlargement/mass, and extensive peritoneal fluid. RESULTS: With a positive ED EVUS, mean physician probability increased for gynecologic (24%) and decreased for both surgical (14%) and medical (20%) disease. With a negative ED EVUS, mean physician probability increased for surgical disease (5.3%) and decreased for gynecologic disease (18.6%). CONCLUSION: Emergency department EVUS changes physician diagnostic decision making in nonpregnant women with undifferentiated RLQ pain.

Prospective comparative trial of endovaginal sonographic bimanual examination versus traditional digital bimanual examination in nonpregnant women with lower abdominal pain with regard to body mass index classification.

OBJECTIVE: We hypothesized that a sonographic bimanual examination (SBME) would improve confidence in the pelvic examination in adult nonpregnant women with lower abdominal conditions compared to a traditional digital bimanual examination (DBME). METHODS: In a prospective comparative study at an urban regional emergency department, an ultrasound-trained group of emergency clinicians performed both an SBME and a DBME on 30 women who required a DBME as part of their evaluation. Patients were divided into 3 groups based on their body mass index (BMI) weight class. Inclusion criteria included lower abdominal pain, age between 18 and 55 years, hemodynamic stability, and BMI of greater than 18.5. Exclusion criteria included pregnancy, hysterectomy, oophorectomy, and recent vaginal surgery. The patient's sequence of examinations was randomized and then performed by a different member of the study group. Examiners assessed their confidence (0%-100%) in 11 components of the pelvic examination. RESULTS: There were higher scores for the SBME compared to the DBME in the overall composite score, cervical position, uterine size, uterine position, uterine tenderness, ovarian size, ovarian tenderness, and presence of an adnexal mass (P < .05), whereas cervical motion tenderness, cervical os opening, and rectovaginal tenderness did not show significant differences. Across BMI classes, the SBME produced high composite and individual examination scores among all examination criteria. In contrast, the DBME revealed significant differences for uterine size, uterine alignment, uterine tenderness, ovarian size, and ovarian tenderness across BMI classes (P < .05). CONCLUSIONS: The SBME provides improved confidence in overall and key aspects of the pelvic examination across BMI classes compared to the DBME.

Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients.

STUDY OBJECTIVE: Our objective is to determine whether a bedside ultrasonographic measurement of optic nerve sheath diameter can accurately predict the computed tomographic (CT) findings of elevated intracranial pressure in adult head injury patients in the emergency department (ED). METHODS: We conducted a prospective, blinded observational study on adult ED patients with suspected intracranial injury with possible elevated intracranial pressure. Exclusion criteria were age younger than 18 years or obvious ocular trauma. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, a single optic nerve sheath diameter was measured 3 mm behind the globe in each eye. A mean binocular optic nerve sheath diameter greater than 5.00 mm was considered abnormal. Cranial CT findings of shift, edema, or effacement suggestive of elevated intracranial pressure were used to evaluate optic nerve sheath diameter accuracy. RESULTS: Fifty-nine patients were enrolled in the study. Average age was 38 years, and median Glasgow Coma Scale score was 15 (interquartile 6 to 15). Eight patients with an optic nerve sheath diameter of 5.00 mm or more had CT findings that correlated with elevated intracranial pressure. The sensitivity for the ultrasonography in detecting elevated intracranial pressure was 100% (95% confidence interval [CI] 68% to 100%) and specificity was 63% (95% CI 50% to 76%). The sensitivity of ultrasonography for detection of any traumatic intracranial injury found by CT was 84% (95% CI 60% to 97%) and specificity was 73% (95% CI 59% to 86%). CONCLUSION: Bedside ED optic nerve sheath diameter ultrasonography has potential as a sensitive screening test for elevated intracranial pressure in adult head injury.

Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension.

The hypothesis of this study states that in emergency department (ED) patients with non-traumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with non-traumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were non-trauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohen's kappa for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57+/-16.7 years, 59% were male, and the mean initial systolic blood pressure was 83+/-11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of kappa=0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with non-traumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.

Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states.

OBJECTIVES: Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS: Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS: Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS: Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.

Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy.

OBJECTIVES: Pelvic ultrasound performed by emergency physicians can identify a definite diagnosis in the majority of symptomatic first-trimester pregnant patients on the initial emergency department (ED) visit. However, a significant minority of such patients are diagnosed as having an indeterminate pregnancy state requiring further testing and consultation. The authors investigated the final outcome of patients with an initial indeterminate ED first-trimester pelvic ultrasound examination in the setting of an interdepartmental protocol to rule out ectopic pregnancy. METHODS: This was an observational prospective cohort study performed at a regional, urban ED with more than 100,000 patient visits over a 13-month period. Pelvic ultrasound for first-trimester patients was prospectively performed by emergency physicians with gynecologic consultation for lack of intrauterine pregnancy (IUP) ultrasound findings. IUP was defined as a fundal gestational sac with either a yolk sac or a fetal pole. Pelvic ultrasounds were classified into diagnostic categories including definite IUP, embryonic demise, molar pregnancy, definite ectopic pregnancy, and indeterminate. For all patients with indeterminate pelvic ultrasound findings, final diagnostic categories and patient outcome were established by the use of patient records, obstetric ultrasound reports, laboratory studies, operative reports, and pathology reports. All patients with ectopic pregnancy were followed for mode of treatment. Descriptive statistics were calculated. RESULTS: A total of 1,490 ED first-trimester pelvic ultrasound examinations were performed over 13 months establishing the following diagnostic rates for initial ED visit: IUP 1,037 (70%), demise 127 (8%), definite ectopic pregnancy 24 (2%), molar pregnancy 2 ( < 1%), and indeterminate 300 (20%). The 300 indeterminate patients were classified using the above protocol into the following final diagnostic categories: embryonic demise 158 (53%), IUP 88 (29%), ectopic pregnancy 44 (15%), and unknown outcome 10 (3%). Indeterminate patients with ectopic pregnancy were treated with methotrexate in 25 of 44 cases (57%) and surgically in 16 of 44 cases (36%); there were no laparotomies. In contrast, ectopic pregnancy patients diagnosed on initial ED visit were treated surgically in 20 of 24 cases (83%), including four laparotomies. CONCLUSIONS: The outcome of symptomatic first-trimester patients with indeterminate ED pelvic ultrasounds is poor, with significantly high rates of embryonic demise and ectopic pregnancy. However, those indeterminate patients with the eventual diagnosis of ectopic pregnancy have a higher rate of medical methotrexate treatment and a reduced rate of invasive surgical treatment compared with ectopic pregnancy patients diagnosed at initial ED visit.

Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study.

OBJECTIVES: To determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency medicine residents. METHODS: This was a prospective, observational, educational study of the impact of a focused training course on the change in physician performance on pre- and postcourse examinations testing competency in goal-directed TTE defined by five criteria: 1). image orientation, 2). anatomy identification, 3). chamber size grading, 4). ventricular function estimation, and 5). pericardial effusion identification. Subjects included were emergency medicine residents with between ten and 20 hours of noncardiac ultrasound didactics and between 20 and >150 proctored noncardiac ultrasound examinations. All underwent five hours of focused echocardiography didactics and one hour of proctored practical echocardiography training designed and implemented by an emergency physician ultrasound director and a cardiologist. Before the start of the training course, participants completed two examinations: 1) written 23-question test on the above concepts and 2) performance of a TTE on a healthy subject testing 16 elements that define a properly performed examination. After the training course, participants again completed both examinations. RESULTS: A total of 21 emergency medicine residents qualified for and underwent standardized testing and training. The percentage correct on the precourse written examination was 54% (95% CI = 50% to 59%), and the postcourse examination score was 76% (95% CI = 71% to 80%) (p < 0.005, paired t-test). The percentage correct on the precourse practical examination was 56% (95% CI = 51% to 60%), and the postcourse examination score was 94% (95% CI = 91% to 96%) (p < 0.005). CONCLUSIONS: A focused six-hour echocardiography training course significantly improved emergency medicine residents' percentage scores on both written and practical examinations testing essential components required for correct goal-directed TTE performance and interpretation.

Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years.

UNLABELLED: Determination of the presence of an abdominal aortic aneurysm (AAA) is essential in the management of the symptomatic emergency department (ED) patient. OBJECTIVES: To identify whether emergency ultrasound of the abdominal aorta (EUS-AA) by emergency physicians could accurately determine the presence of AAA and guide ED disposition. METHODS: This was a prospective, observational study at an urban ED with more than 100,000 annual patient visits with consecutive patients enrolled over a two-year period. All patients suspected to have AAA underwent standard ED evaluation consisting of EUS-AA, followed by a confirmatory imaging study or laparotomy. AAA was defined as any measured diameter greater than 3 cm. Demographic data, results of confirmatory testing, and patient outcome were collected by retrospective review. RESULTS: A total of 125 patients had EUS-AA performed over a two-year period. The patient population had the following characteristics: average age 66 years, male 54%, hypertension 56%, coronary artery disease 39%, diabetes 22%, and peripheral vascular disease 14%. Confirmatory tests included radiology ultrasound, 28/125 (22%); abdominal computed tomography, 95/125 (76%); abdominal magnetic resonance imaging, 1/125 (1%); and laparotomy, 1/125 (1%). AAA was diagnosed in 29/125 (23%); of those, 27/29 patients had AAA on confirmatory testing. EUS-AA had 100% sensitivity (95% CI = 89.5 to 100), 98% specificity (95% CI = 92.8 to 99.8), 93% positive predictive value (27/29), and 100% negative predictive value (96/96). Admission rate for the study group overall was 70%. Immediate operative management was considered in 17 of 27 (63%) patients with AAA; ten patients were taken to the operating room. CONCLUSIONS: EUS-AA in a symptomatic population for AAA is sensitive and specific. These data suggest that the presence of AAA on EUS-AA should guide urgent consultation. Emergency physicians were able to exclude AAA regardless of disposition from the ED.

Determination of left ventricular function by emergency physician echocardiography of hypotensive patients.

OBJECTIVE: To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. METHODS: Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. RESULTS: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). CONCLUSIONS: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.

Residency training in emergency ultrasound: fulfilling the mandate.

Although bedside ultrasound is listed in the Model of the Clinical Practice of Emergency Medicine as an integral diagnostic procedure, the manner in which the didactic, hands-on, and experiential components of emergency ultrasound are taught is not specifically prescribed by the Residency Review Committee for Emergency Medicine (RRC-EM) or any single sponsoring group. Seven professional organizations [the American Board of Emergency Medicine (ABEM), the American College of Emergency Medicine (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents Association (EMRA), the National Association of EMS Physicians (NAEMSP), the RRC-EM, and the Society for Academic Emergency Medicine (SAEM)] developed the Scope of Training Task Force, with the goal of identifying emerging areas of clinical importance to the specialty of emergency medicine, including emergency department (ED) ultrasound. The Task Force then identified a group of recognized authorities to thoughtfully address the issue of ED ultrasound training. This report represents a consensus of these identified experts on how emergency ultrasound training should be incorporated into emergency medicine residency programs.

Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture.

Two patients who presented to the Emergency Department (ED) in shock with severe pelvic fractures were evaluated for intra-abdominal injury with a focused assessment with sonography in trauma (FAST) examination. Free intraperitoneal fluid was identified in the hepato-renal recess of both patients. At laparotomy both patients were found to have extensive uroperitoneum resulting from intraperitoneal bladder rupture and no other intra-abdominal injuries. The source of shock in both cases was ultimately determined to be arterial hemorrhage from pelvic vessels. The utility of FAST examinations in the setting of major pelvic injury is relatively unstudied. Coincident injuries make the evaluation for source of hemorrhage in this subset of patients challenging. This is a report of sonographic intraperitoneal fluid in the setting of major pelvic injury and hemodynamic instability found to be uroperitoneum and not hemoperitoneum.

The core content of clinical ultrasonography fellowship training.

The purpose of developing a core content for subspecialty training in clinical ultrasonography (US) is to standardize the education and qualifications required to provide oversight of US training, clinical use, and administration to improve patient care. This core content would be mastered by a fellow as a separate and unique postgraduate training, beyond that obtained during an emergency medicine (EM) residency or during medical school. The core content defines the training parameters, resources, and knowledge of clinical US necessary to direct clinical US divisions within medical specialties. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear in future examinations. This article describes the development of the core content and presents the core content in its entirety.

Ultrasound-guided oblique approach for peripheral venous access in a phantom model.

BACKGROUND: Ultrasound (US) vascular guidance is traditionally performed in transverse (T) and longitudinal (L) axes, each with drawbacks. We hypothesized that the introduction of a novel oblique (O) approach would improve the success of US-guided peripheral venous access. We examined emergency physician (EP) performance using the O approach in a gel US phantom. METHODS: In a prospective, case control study, EPs were enrolled from four levels of physician experience including postgraduate years one to three (PGY1, PGY2, PGY3) and attending physicians. After a brief training session, each participant attempted vessel aspiration using a linear probe in T, L, and O axes on a gel US phantom. Time to aspiration and number of attempts to aspiration were recorded. The approach order was randomized, and descriptive statistics were used. RESULTS: Twenty-four physicians participated. The first-attempt success rate was lower for O, 45.83%, versus 70.83% for T (p = 0.03) and 83.33% for L (p = 0.01). The average time to aspiration was 12.5 s (O) compared with 9.47 s (T) and 9.74 s (L), respectively. There were no significant differences between all four groups in regard to total amount of time and number of aspiration attempts; however, a trend appeared revealing that PGY3 and attending physicians tended to aspirate in less time and by fewer attempts in all three orientations when compared with the PGY2 and PGY1 physicians. CONCLUSION: In this pilot study, US-guided simulated peripheral venous access using a phantom gel model in a mixed user group showed that the novel oblique approach was not initially more successful versus T and L techniques.

The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial.

OBJECTIVES: Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. METHODS: This was a prospective randomized double-blinded trial set in emergency department (ED) clinical care rooms. Volunteer subjects with no history of cardiac disease or hypertension fasted for 12 hours. Subjects were randomly assigned to receive IV 0.9% saline bolus of 2 (control group), 10, or 30 mL/kg over 30 minutes. IVC-US was performed before and 15 minutes after each fluid bolus. RESULTS: Forty-two fasting subjects were enrolled. Analysis of variance (ANOVA) comparison showed that IVC-US was unable to detect any significant difference between the control group and those given either 10 or 30 mL/kg fluid, whether using maximum or minimum IVC diameter or caval index (IVC-CI). The groups receiving 10 and 30 mL/kg each had a statistically significant change in IVC-CI; however, the 30 mL/kg group had no significant change in either of the mean IVC diameters. CONCLUSIONS: Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.

Comparison of serial qualitative and quantitative assessments of caval index and left ventricular systolic function during early fluid resuscitation of hypotensive emergency department patients.

OBJECTIVES: The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. METHODS: This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship-trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. RESULTS: Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. CONCLUSIONS: This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.