Point-of-care ultrasonography for cardiovascular conditions in family practice: between risk and opportunity.

Several articles have appeared in the medical literature on the use of ultrasound in primary care. Point-of-care ultrasound refers to ultrasound protocols performed at the bedside to evaluate many conditions such as aortic aneurysm or assessment of left ventricular function by estimation of ejection fraction. Primary care physicians can play a key role in evaluating such conditions for their patients. It should be considered that the use of ultrasound in general practice can not only be an aid to diagnosis but also an active screening tool, accessible even to those with basic training in ultrasound; the left ventricle and large abdominal vessels are indeed clearly visible with this technique, which with little training can become accessible to many. In a working organization, so few trained physicians would be sufficient to screen the target population of the entire group and extend the assessment to a large number of participants.

Ultrasound-Guided Erector Spinae Plane Block: A Case Series Demonstrating Utility for Acutely Painful Conditions in the Emergency Setting.

Ultrasound-guided erector spinae plane block (ESPB) has emerged as a valuable technique in pain management. Though frequently used in chronic and postoperative pain, it remains underutilized in the emergency department (ED) setting. In particular, this block has become attractive because it is rapid, safe, and efficacious for a variety of different pain syndromes that are commonly encountered in the emergency department setting. Of particular importance is that this block results in pure sensory blockade, allowing patient movement after the procedure has been performed. This case series explores the efficacy of the ESPB in various clinical scenarios, including refractory cervical radiculopathy, rib fractures, obstructive nephrolithiasis, and sciatica. Each of these patients presented with symptoms of refractory aggressive pain management strategies, including non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen, narcotics, muscle relaxers, and ketamine. After undergoing ESPB, the patients were able to be successfully discharged without return visits to the emergency department for the return of their pain. This case series aims to show the utility of this procedure for refractory painful conditions and also reviews other indications where the block may be used. While previous reports have shown the utility of this block at individual levels, we present the flexibility of this block being used at multiple levels of the spine.

An Efficient Approach to the Inpatient Syncope Workup.

This review aims to provide hospitalists with a streamlined understanding of the evaluation of syncope, a commonly encountered complaint in hospital medicine. Authors conducted a literature review using the keyword 'syncope' to compile current evidence and recommendations regarding the categorization, risk stratification, and diagnostic evaluation of syncope. The review outlines the categorization of syncope into cardiac, neurally mediated, and orthostatic types, detailing the clinical features, etiologies, and differential diagnoses of each. It provides a structured framework for history-taking, physical examination, orthostatic vital sign assessment, and risk stratification to guide clinicians in efficiently identifying high-risk patients requiring urgent intervention. Additionally, diagnostic modalities including electrocardiography, echocardiography, and point-of-care ultrasound are discussed, along with their respective indications and limitations. By embracing standardized approaches and evidence-based practices outlined in this review, hospitalists can optimize resource utilization, streamline patient care, and improve outcomes in patients presenting with syncope.

Utility of Point-of-Care Ultrasound During Prone Positioning Cardiopulmonary Resuscitation.

This report describes a 34-year-old male admitted to the medical intensive care unit (ICU) who sustained cardiac arrest while in prone positioning. Prone position CPR was initiated, and the utilization of point-of-care ultrasound (POCUS) during CPR was necessary to assess compression quality. Specifically, the popliteal was observed using POCUS to gauge the adequacy of compressions and subsequent perfusion during prone position CPR. This approach provides insight into assessing the effectiveness of chest compressions in a challenging prone position, potentially improving outcomes in similar cases. Further research and application of POCUS in this context may enhance the quality of CPR and patient care during cardiac arrest events in prone positioning.

Yamaguchi Syndrome: An Important Consideration in the Differential Diagnosis of Chest Pain in the Emergency Department.

Non-obstructive hypertrophic cardiomyopathy, or apical hypertrophic cardiomyopathy (ApHCM), also referred to as Yamaguchi syndrome, is a type of hypertrophic cardiomyopathy (HCM) characterized by significant thickening of the left ventricular apex without blockage in the left ventricular outflow tract. It is a very rare variant of HCM. Patients with non-obstructive HCM often experience symptoms such as chest pain, palpitations, shortness of breath, and syncope, which may resemble those seen in various cardiovascular and non-cardiac conditions. Yamaguchi syndrome presents as a challenging yet manageable condition in the ED. Early recognition, accurate diagnosis, and appropriate management are crucial for better outcomes. We report a case of a young female who presented to the ED with breathlessness and chest pain. The ECG findings suggested acute coronary syndrome (ACS), but echocardiography and cardiac biomarkers indicated otherwise, leading to the diagnosis of Yamaguchi Syndrome.

Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings.

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

Lung Ultrasound as an Adjunct to Pulse Oximetry and Respiratory Symptoms in the Diagnosis of Freediving-Induced Pulmonary Syndrome.

INTRODUCTION: B-lines on lung ultrasound have been found in asymptomatic competitive breath-hold divers, but their significance and time to resolution are not well understood. We sought to investigate the relationship between B-lines, oxygen saturation, and respiratory symptoms after competitive dives to diagnose pulmonary injury. METHODS: We performed lung ultrasounds before (predive), immediately after (postdive), and within 1 h (follow-up) of a competitive dive. B-lines were counted in each intercostal space in the anterior, lateral, and posterior lung fields, and the highest number of B-lines within a space was recorded for each lung region. At follow-up, each diver's oxygen saturation and respiratory symptoms were recorded. Statistical analysis included the Kruskal-Wallis test, Spearman's correlation, and sensitivity and specificity calculations. RESULTS: Forty-four divers completed 143 individual dives of four different disciplines. The median number of B-lines was 0 (IQR inclusive=0) predive, 1 (IQR=3) postdive, and 0 (IQR=1) at follow-up. There was a significant difference in total B-lines between measurement times (p<0.001). Sensitivity and specificity of hypoxemia, clinically significant B-lines, and both measures in tandem in detecting respiratory symptomatology were 52% and 76%, 24% and 92%, and 24% and 95%, respectively. CONCLUSIONS: B-lines are a common phenomenon in competitive breath-hold divers on surfacing and decrease within 1 h, suggesting a physiologic fluid shift. B-lines are negatively correlated with oxygen saturation, indicating that extravascular fluid impairs gas exchange in the lung. Neither hypoxemia nor clinically significant B-lines were found to be reliable indicators for respiratory symptomatology, suggesting that there may be multiple phenotypes of freediving-induced pulmonary syndrome.

What is the utility of point-of-care ultrasound for suspected pulled elbow? A single-centre case series.

Radial head subluxation, known as pulled elbow or nursemaid's elbow, is a common presentation to the Paediatric Emergency Department (PED). Fifty per cent of children present following an unwitnessed injury or with an atypical history. Furthermore, examination can be difficult in an upset or frightened child meaning the precise location of the injury is not always easily identifiable. Many children receive upper limb x-rays unnecessarily and others undergo attempted reduction for suspected pulled elbow when a fracture is the cause of their pain. OBJECTIVE: To evaluate the ability of point-of-care ultrasound (POCUS) to correctly identify cases of suspected pulled elbow. METHODS: A retrospective review of patients aged 0-5 years presenting to the PED of our large District General Hospital from November 2020 to November 2022. We reviewed the electronic medical records of all patients presenting with a triage category of 'elbow Injury'. We excluded patients presenting with obvious deformity, significant swelling and history of road traffic collision or other major trauma mechanism such as a fall from a height. POCUS was carried out by the authors according to pre-existing clinical protocols. RESULTS: Thirty-seven patients underwent POCUS. Twenty-nine had a typical history and all had a positive POCUS for pulled elbow. Of the remaining eight patients with an atypical history, three were found to have a positive POCUS compared to unaffected elbow. Five patients with an atypical history had negative POCUS findings and were diagnosed as soft tissue injuries after further assessment. All 32 with positive sonographic signs had a final diagnosis of pulled elbow, meaning the specificity was 100% (47.8-100) (P = 0.00003). The sensitivity was 100%. CONCLUSION: Use of POCUS by appropriately trained clinicians, as an extension of a clinical examination, in this retrospective study reliably confirmed pulled elbow. This has the potential to reduce both unnecessary radiation as well as the time in the emergency department for the child and their carers.

Global survey on point-of-care ultrasound (pocus) use in child surgery.

PURPOSE: To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery. METHODS: An electronic survey was disseminated via the GICS (Global Initiative of Children's Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery. RESULTS: Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available. CONCLUSIONS: Ultrasound is critically important in children's surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance.

Optimising POCUS programs: A summary of EMUG's recommendations for the development and maintenance of ED POCUS programs.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by Clinical Leads in Ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective, and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Recommendations for developing a comprehensive point-of-care ultrasound (POCUS) program in the emergency department: an Emergency Medicine Ultrasound Group advocacy statement.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes the risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by clinical leaders in ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Prospective Comparison of Nine Different Handheld Ultrasound (HHUS) Devices by Ultrasound Experts with Regard to B-Scan Quality, Device Handling and Software in Abdominal Sonography.

BACKGROUND: The HHUS market is very complex due to a multitude of equipment variants and several different device manufacturers. Only a few studies have compared different HHUS devices under clinical conditions. We conducted a comprehensive prospective observer study with a direct comparison of nine different HHUS devices in terms of B-scan quality, device handling, and software features under abdominal imaging conditions. METHODS: Nine different HHUS devices (Butterfly iQ+, Clarius C3HD3, D5CL Microvue, Philips Lumify, SonoEye Chison, SonoSite iViz, Mindray TE Air, GE Vscan Air, and Youkey Q7) were used in a prospective setting by a total of 12 experienced examiners on the same subjects in each case and then assessed using a detailed questionnaire regarding B-scan quality, handling, and usability of the software. The evaluation was carried out using a point scale (5 points: very good; 1 point: insufficient). RESULTS: In the overall evaluation, Vscan Air and SonoEye Chison achieved the best ratings. They achieved nominal ratings between "good" (4 points) and "very good" (5 points). Both devices differed significantly (p < 0.01) from the other seven devices tested. Among the HHUS devices, Clarius C3HD3 and Vscan Air achieved the best results for B-mode quality, D5CL Microvue achieved the best results for device handling, and SonoEye Chison and Vscan Air achieved the best results for software. CONCLUSIONS: This is the first comprehensive study to directly compare different HHUS devices in a head-to-head manner. While the majority of the tested devices demonstrated satisfactory performance, notable discrepancies were observed between them. In particular, the B-scan quality exhibited considerable variation, which may have implications for the clinical application of HHUS. The findings of this study can assist in the selection of an appropriate HHUS device for specific applications, considering the clinical objectives and acknowledging the inherent limitations.

Comparing New Smartphone-Connected Handheld Ultrasound Device vs. Traditional Ultrasound in Vitreo-Retinal Disease Diagnosis.

(1) Background: Ocular emergencies account for 1.5-3% of emergency department (ED) visits and require urgent diagnosis to prevent serious complications. Ultrasonography is a crucial, non-invasive diagnostic tool for these conditions but traditionally lacks portability and integration with modern electronic smart devices. The purpose of this study was to assess the accuracy and performance of a new handheld ultrasound device in comparison to a conventional cart-based sonographic machine in patients attending to the ED for vitreo-retinal diseases. (2) Methods: three specialists in ophthalmology, with at least 4-year experience in vitreo-retinal diseases and eye ultrasound, evaluated images of 50 eyes with both portable and traditional ultrasound probes. Each specialist made the diagnosis based on the images captured with both probes and then rated their overall image quality and confidence of diagnosis with a five-point Likert scale. The concordance of diagnosis between the two probes was evaluated. (3) Results: The sample comprised 42 patients. Twenty (40%) healthy eyes and thirty eyes with the following vitreo-retinal interface conditions were examined: 12 retinal detachment (24%), 8 vitreous hemorrhage (16%), and 10 posterior vitreous detachment (20%). The overall accuracy of the two devices appeared to be comparable (70.7% vs. 69.3%). The Butterfly iQ+ probe showed similar sensitivity in retinal detachment diagnosis (91.7% vs. 94.4% of the Accutome B-scan Pro), while it showed poor performance in diagnosing posterior vitreous detachment (sensitivity = 27.2%); (4) Conclusions: The Butterfly iQ+ device demonstrated high sensitivity in the diagnosis of retinal detachment. Significant adjustments are still needed to improve the resolution of the vitreous body.

Role of Imaging in Diagnosis and Management of COVID-19: Evidence-Based Approaches.

Imaging has been demonstrated to play a crucial role in both the diagnosis and management of COVID-19. Depending on resources, pre-test probability, and risk factors for severe disease progression, real-time polymerase chain reaction (RT-PCR) testing may be followed by chest radiography (CXR) or chest computed tomography (CT) to further aid in diagnosis or excluding COVID-19 disease. SARS-CoV-2 has been shown not only to pathologically impact the pulmonary system, but also the cardiovascular, gastrointestinal, and neurological systems to name a few. Imaging has again proven useful in further investigating and managing extrapulmonary disease, with the use of echocardiogram, CT angiography of the cardiovascular and cerebrovascular structures, MRI of the brain, as well as ultrasound of the abdomen and CT of the abdomen and pelvis proving particularly useful. Research in artificial intelligence and its application in the diagnosis of COVID-19 and disease severity prediction is underway, and point-of-care ultrasound is an emerging bedside technique that may allow for more efficient and timely diagnosis of COVID-19.

Ultrasound-Guided Peripheral Intravenous Access Training: A Prospective Observational Study of Emergency Nurses.

Background Ultrasound-guided peripheral intravenous (USGPIV) placement is more successful, comfortable, and longer lasting than traditional landmark-based IVs. While many hospitals have protocols for becoming credentialed in this skill, there is little information available about the USGPIV success rate during and after training. Objectives This pilot study aimed to quantify USGPIV attempts by emergency nurses undergoing USGPIV training and to determine if 10 successful USGPIVs predicted success in the next USGPIV. The secondary aims were to determine failure points for unsuccessful USGPIVs and the time to complete training. Methods Sixteen emergency nurses with no prior USGPIV experience were enrolled. Participants completed a one-hour didactic session and one hour of hands-on training with vein simulators. Participants had direct observation of all USGPIV attempts up until 10 successful cannulations. Each attempt was recorded along with reasons for USGPIV attempt failure and the time required to become credentialed. Results Participants attempted 200 USGPIVs with a success rate of 80% (160/200). Fourteen participants completed 10 successful USGPIVs, requiring a median of 11 attempts (IQR 10-13) and a success rate of 92.9% (13/14) on subsequent USGPIV attempts. Participants required a median observation time of 4.13 hours (IQR: 3.94-4.75). The most common point of failure was using dynamic ultrasound guidance to maintain needle tip visualization. Conclusions USGPIVs are a valuable skill that requires time and practice. Emergency nurses with no prior USGPIV experience can achieve the requirements for hospital credentialing and success on subsequent USGPIV insertion by completing 10 successful USGPIVs after a two-hour training session and four hours of direct observation.

Assessment of Point-of-Care Ultrasound (POCUS) Knowledge Among Lebanese Medical Residents.

Over the past few years, point-of-care ultrasound (POCUS) has emerged as a critical diagnostic tool in emergency medicine, providing real-time imaging at the bedside. This study aims to assess POCUS knowledge and competency among medical residents in Lebanon, identify possible gaps and deficiencies in their training, and recommend guidelines for further improvement of the curriculum in Lebanese medical schools and residency programs. Our study reveals that 58.3% (N=119) of resident doctors from multiple specialties in Lebanon have only basic knowledge about POCUS, 19.6% (N=40) have no knowledge, and only 21.6% (N=44) have sufficient knowledge to perform diagnostic studies on a routine basis. Lebanese medical residents currently possess suboptimal POCUS knowledge and proficiency due to disparities in training and educational obstacles. To address this, residency programs should focus on standardized POCUS training, simulation-based learning, and faculty development. This approach will help ensure residents gain the necessary skills to use POCUS effectively in clinical practice.

Prevalence of undiagnosed stage B heart failure among emergency department patients.

INTRODUCTION: Heart failure (HF) is associated with significant morbidity, mortality, and health care costs. Stage B HF is defined as structural heart disease prior to developing symptomatic HF. If identified early in the disease process, preventative measures may be implemented to slow disease progression to Stage C (symptomatic) or Stage D (refractory) HF. Previous research has focused on outpatient screening for HF in the primary care setting; however, there are limited data on Stage B HF screening in the Emergency Department (ED) setting. The objective of this study was to determine the prevalence of undiagnosed Stage B HF among those with cardiovascular risk factors in the ED setting and identify which risk factors were associated with a greater risk of having Stage B HF. METHODS: A prospective, observational study was performed in a single, urban academic ED from 07/2023 to 05/2024. Inclusion criteria were age ≥ 45 years with hypertension, diabetes, obesity, coronary heart disease, previous cardiotoxic chemotherapy, or family history of HF. Exclusion criteria included signs or symptoms of HF, known history of HF, valvular disease, current atrial fibrillation, or primary language other than English. A focused cardiac ultrasound was performed and interpreted by ultrasound-fellowship trained emergency physicians. Sonographers assessed systolic function as ejection fraction <50 % using visual assessment in at least two different views. Sonographers assessed diastolic dysfunction as an E/A ratio < 0.8, or if ≥2 of the following were present: septal e' < 7 cm/s or lateral e' < 10 cm/s, E/e' ratio > 14, or left atrial volume > 34 mL/m2. Descriptive statistics were performed, followed by comparative analyses and regression modeling. RESULTS: 209 participants were included in the study, with a mean age of 60 years and 51.7 % women. Of these, 125 (59.8 %) had undiagnosed Stage B HF, with 13 (10.4 %) having systolic dysfunction and 112 (89.6 %) having isolated diastolic dysfunction. Among those with isolated diastolic dysfunction, 44 (39.3 %) were grade I, 66 (58.9 %) were grade II, and 2 (1.8 %) were grade III. Predictors of undiagnosed Stage B HF included age (odds ratio 1.06; 95 % CI 1.02 to 1.10) and BMI (odds ratio 1.06; 95 % CI 1.01 to 1.10). CONCLUSION: A large majority of ED patients with cardiovascular risk factors had undiagnosed Stage B HF. Age and obesity were associated with a higher risk of Stage B HF. This provides an opportunity for early identification and intervention for patients with undiagnosed Stage B HF to reduce progression to more severe HF.

Barriers to learning and performing point-of-care ultrasound (POCUS): An integrative review.

BACKGROUND: Point-of-care ultrasound (POCUS) is a valuable adjunct to traditional imaging and physical exam. Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) serve as primary providers for acutely ill patients across the country, yet there is limited literature to describe the AGACNP experience with POCUS training and clinical application. PURPOSE: This integrative review was to describe barriers to learning and performing POCUS that AGACNP's experience, identify necessary components of a successful POCUS curriculum, and synthesize evidence to propose solutions. METHOD: CINAHL, PubMed, and Ovid databases were systematically searched for publications. Two reviewers completed the quality appraisal of the 12 articles identified during the literature search. RESULTS: Common barriers include: formal training; access to ultrasound machines; quality assurance; time to perform exams; inability to use findings in documentation/decision making. Low confidence may be an underrepresented barrier. Successful training programs include an introductory class with mixed didactic and hands-on training, training with live models, direct supervision and image review by experts, and longitudinal training. CONCLUSION: Adult-Gerontology Acute Care Nurse Practitioners are capable of learning and incorporating POCUS use into clinical practice. Broad solutions can be instituted to remove barriers, but more research is needed to describe necessary components of a successful POCUS training program.

Venous Excess Ultrasound for Fluid Assessment in Complex Cardiac Patients With Acute Kidney Injury.

INTRODUCTION: The introduction of point-of-care ultrasound (POCUS) into clinical practice has revolutionized bedside hemodynamic assessment in recent years. POCUS has expanded its utility to include evaluating and grading venous congestion through Doppler analysis of venous blood flow. This innovative technique, VExUS (venous excess ultrasound), comprehensively evaluates venous congestion across multiple sites, including the inferior vena cava (IVC), hepatic vein, portal vein, and intrarenal vasculature. The aim of the current study was to determine whether venous excess ultrasound can help guide fluid therapy in complex patients with acute kidney injury (AKI) in addition to the standard physical examination and imaging. METHODS: Our current study shows instructive 18 clinical adult cases (enrolled between January 2024 and May 2024) to determine whether venous excess ultrasound can help guide fluid therapy in complex cardiac patients with acute kidney injury, in addition to the standard physical examination and imaging. RESULTS: VExUS was pivotal in guiding fluid therapy in all complex patients with AKI and suspected right ventricular dysfunction. By integrating VExUS findings with clinical data and cardiac ultrasound results, clinicians were able to make patient-favouring decisions regarding fluid management, diuresis, and vasopressor therapy, addressing critical aspects of conditions such as septic shock, heart failure, and acute kidney injury. CONCLUSIONS: In our study of VExUS in sick patients with AKI, we concluded that VExUS proved to be a valuable tool for fluid assessment and management. By providing real-time visualization of venous congestion, VExUS allowed for more precise and individualized fluid management strategies. This led to improved decision-making regarding fluid administration and removal, helping to prevent both fluid overload and hypovolemia. Consequently, the use of VExUS contributed to better clinical outcomes in patients with AKI, demonstrating its potential as a critical component in the management of fluid balance in this vulnerable patient population.

POCUS for pediatric appendicitis in the pediatric emergency department: An 8-year retrospective review.

BACKGROUND: In many centers, pediatric radiology-performed ultrasound and/or POCUS fellowship training are not readily available. OBJECTIVE: To present our experience using point of care ultrasound (POCUS) in a pediatric emergency medicine training program without POCUS fellowship-trained staff, and to demonstrate that POCUS of the appendix is feasible outside the context for POCUS fellowship training. METHODS: We identified children diagnosed with appendicitis or periappendiceal abscess from June 2016 to June 2024. Variables reviewed include details of PED visit such as presenting symptoms, laboratory and imaging results, and PED treatment, as well as surgical report and pathology result. We evaluated the frequency and performance characteristics of POCUS over the study period. RESULTS: 999 children were diagnosed with appendicitis. POCUS was performed in 360 of 845 cases (43%) of histology-confirmed appendicitis and in 19 of 69 cases (28%) in which histology was negative for appendicitis. Both the number of POCUS examinations for appendicitis and the percentage of examinations correctly identifying appendicitis steadily increased over the study period. Accuracy was highest in the 5-10-year age range and lowest for females from 10 to 15 years. In 96% of cases with a pathology result of appendicitis and a positive POCUS examination, POCUS correctly identified appendicitis. However, only 6 of 19 POCUS examinations in children without appendicitis on histology found no appendicitis. Performance of POCUS for appendicitis was significantly associated with increased opioid administration and a 20-min mean decrease in length of pediatric emergency department stay. CONCLUSIONS: POCUS for appendicitis within the context of PEM fellowship training is feasible and associated with decreased length of stay.