POCUS for Diastolic Dysfunction: A Review of the Literature.

Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency.

Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.

Ultrasound in Pregnancy.

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

Quantitative and Qualitative Analysis of Emergency Physician Performed Biparietal Diameter Estimate for Gestational Age.

BACKGROUND: An accurate estimation of fetal gestational age is essential for the management of pregnant patients who present to the emergency department (ED). Point-of-care-ultrasound (POCUS) is an integral part of emergency medicine training and includes measurement of fetal gestational age by the biparietal diameter (BPD) method. OBJECTIVES: In this study we performed a quantitative assessment of emergency physician (EP)-performed BPD estimate of gestational age to identify the percentage of studies performed in our department that had an estimated gestational age within 14 days of an adjusted radiological or obstetrical estimation. METHODS: We performed a chart review of our ED ultrasound database and electronic medical records for cases where a BPD measurement was performed by an EP. We recorded the ED gestational age estimate in days and the radiological or obstetrical estimate of gestational age in days. We then calculated the difference in days between the two examinations. We used a normal binomial approximation to calculate 95% confidence intervals. A secondary analysis looked at the quality of the images based on measurement placement and the view obtained. RESULTS: Seventy-four cases met eligibility criteria; of those, 67 (91%) had a gestational age estimation within 14 days of the adjusted radiological or obstetrical estimate (95% confidence interval 81-96%). CONCLUSION: This study shows that EP-performed BPD measurements for gestational age are quantitatively accurate, with 91% of estimates within 14 days of a standard radiological or obstetrical estimation.

'Diagnosis of Boerhaave's Syndrome With Aid of Bedside Ultrasound.

BACKGROUND: Boerhaave's syndrome is characterized by transmural rupture of the distal esophagus in the setting of increased intraluminal pressures combined with negative intrathoracic pressure. It is a rare condition with high mortality (20-50% mortality rate). CASE REPORT: This is a case of a 47-year-old man who appeared acutely ill, presenting with shortness of breath, chest and abdominal pain, and diagnosed with Boerhaave's syndrome with the assistance of bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: Emergency physicians must have a heightened suspicion of this diagnosis in patients presenting with chest and abdominal pain and can use bedside ultrasound skills to aid with diagnosis.

Real-Time Remote Tele-Mentored Echocardiography: A Systematic Review.

Background and Objectives: Real-time remote tele-mentored echocardiography (RTMUS echo) involves the transmission of clinical ultrasound (CU) cardiac images with direct feedback from a CU expert at a different location. In this review, we summarize the current uses of RTMUS to diagnose and manage cardiovascular dysfunction and discuss expanded and future uses. Materials and Methods: We performed a literature search (PubMed and EMBase) to access articles related to RTMUS echo. We reviewed articles for selection using Covidence, a web-based tool for managing systematic reviews and data were extracted using a separate standardized collection form. Results: Our search yielded 15 articles. Twelve of these articles demonstrated the feasibility of having a novice sonographer mentored by a tele-expert in obtaining a variety of cardiac ultrasound views. The articles discussed different technological specifications for the RTMUS system, but all showed that adequate images were able to be obtained. Overall, RTMUS echo was found to be a positive intervention that contributed to patient care. Conclusion: RTMUS echo allows for rapid access to diagnostic imaging in various clinical settings. RTMUS echo can help in assessing patients that may require a higher level of isolation precautions or in other resource-constrained environments. In the future, identifying the least expensive way to utilize RTMUS echo will be important.

Transesophageal Echocardiography Training of Emergency Physicians Through an E-Learning System.

BACKGROUND: Transesophageal echocardiography (TEE) has been shown to be a powerful tool that emergency physicians can use to guide resuscitation efforts during cardiac arrest. Currently, there is no standardized curriculum to teach TEE to emergency physicians. OBJECTIVE: We hypothesized that the use of a pilot training course combining interactive e-learning and hands-on simulation would increase the percentage of students achieving a score of ≥80% on a multiple-choice test of knowledge and increase self-reported comfort using TEE. METHODS: We designed a 2.5-h TEE course for emergency physicians and medical intensive care unit fellows. Participants took a test of knowledge and a survey of comfort-both online-before, just after, and 4 weeks after taking the course. Survey responses measured participants self-reported comfort with using TEE in clinical practice. A normal binomial approximation was used to calculate the 95% confidence interval. RESULTS: Of the 3 tests of knowledge, 15 participants completed all tests. Of the surveys of comfort, 31 participants completed the precourse survey, 32 completed the postcourse survey, and 19 completed the 4-week follow-up survey. The proportion of students scoring ≥80% improved from 40% on the precourse test to 80% on the postcourse test (95% confidence interval 1-79). The proportion of students indicating comfort with using TEE improved from 3% precourse to 53% postcourse (95% confidence interval 28-71). CONCLUSIONS: A TEE training course resulted in a 50% increase in surveyed participants feeling comfortable using TEE in cardiac arrest and a 40% increase in participants scoring ≥80% on a test of knowledge.

Point-of-Care Teleultrasound: A Systematic Review.

Background: Telemedicine and point-of-care ultrasound have merged to create a field known as teleultrasound (TUS). Real-time TUS involves the transmission of bedside ultrasound (US) images with direct feedback from an US expert. In this review, we summarize the current uses of real-time TUS and discuss its potential future uses. Methods: We performed a literature search (PubMed and EMBase) to assess articles related to real-time TUS. Data were extracted using a standardized collection form, and relevant articles were separated into feasibility or clinical studies. Results: Our search yielded 45 articles, with most of the reports taking place in resource-constrained settings. A large portion of the studies discussed the use of the focused assessment with sonography in trauma exam. Others included musculoskeletal, vascular, and echocardiography. Conclusion: Real-time TUS allows for rapid access to diagnostic imaging in various clinical settings. This technology is poised to expand with many uses on the horizon.

The Use of Transesophageal Echocardiography During Cardiac Arrest Resuscitation: A Literature Review.

We propose that transesophageal echocardiography (TEE) can be used to guide cardiac arrest resuscitation. We undertook a literature search (Medline and EMBase) to assess articles on that topic. Our search yielded 55 articles falling into 3 categories: TEE used in operating rooms, TEE used in emergency departments, and TEE used in other settings. In many cases, TEE changed the direction of the resuscitation; however, it is unclear whether TEE changed patient-oriented outcomes, such as neurologically intact survival. Few adverse events related to TEE have been documented. There is growing evidence that physicians can learn to use TEE during resuscitations and apply the findings to clinical decisions.

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection.

BACKGROUND: Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition. CASE REPORT: We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.