Using a Linear Probe Ultrasound for the Detection of First-Trimester Pregnancies in the Emergency Department.

Linear probe point-of-care ultrasound (LPUS) presents a less invasive alternative for identifying intrauterine pregnancies (IUPs) compared to usual practice (transabdominal (TAUS) or transvaginal (TVUS) ultrasound). TAUS and TVUS can be invasive or produce lower-resolution images than LPUS. The purpose of this study is to determine whether a linear probe alone can identify first-trimester IUPs. A convenience sample of 21 patients were enrolled at the University of California Irvine ED during a 7-month period. The inclusion criteria were English- or Spanish-speaking women (≥18 years) in their first trimester of pregnancy (≤12 weeks pregnant) with a body mass index (BMI) of <35. The exclusion criteria were psychiatric, incarcerated, or cognitively impaired patients. An ED physician performed LPUS and ordered a confirmatory ultrasound. The 21 patients enrolled had a mean age of 28.6 ± 6.60 years, BMI of 26.6 ± 5.03, and gestational age of 7.4 ± 2.69 weeks. Considering the 95% confidence interval, we are 97.5% confident that the sensitivity and specificity of LPUS to identify IUPs does not exceed 67.1% and 93.2%, respectively. Our pilot data did not demonstrate that LPUS can independently visualize IUPs in first-trimester patients.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

INTRODUCTION: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. METHODS: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. RESULTS: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). CONCLUSION: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

Evaluation of Adherence to Emergency Department Point-of-Care Ultrasound Documentation and Billing Following Intervention.

Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%-63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%-74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.

Serratus anterior plane block as a bridge to outpatient management of severe rib fractures: a case report.

Rib fractures account for a significant number of emergency department visits each year. A patient's disposition often depends on the severity of rib fractures, comorbidities, and ability to achieve adequate analgesia. We present a 44-year-old male patient with severe pain secondary to rib fractures. The initial disposition was to admit for pain control. However, upon performing a serratus anterior plane block, patient was functionally appropriate for discharge with proper return precautions. Serratus anterior plane block is within the skillset of the emergency physician and can be used to achieve analgesia for rib fractures without the sedative and respiratory depressive effects associated with opioids.

A comparison of handheld and standard ultrasound in Swiss medical students.

BACKGROUND: The use of ultrasound (US) within healthcare has inspired the development of new US technology. There have been few studies comparing the use of handheld US to standard US for medical education. This research aims to determine whether a handheld US device can provide a comparable primary learning experience to that of a standard US machine. METHODS: Over two days of instruction, participants were taught and evaluated on core US fundamentals. The standard group received instruction on standard US machines, while the handheld group received instruction on handheld US devices. Participants completed a qualitative survey regarding their experience. Six hundred and four images were obtained and graded by two emergency medicine physicians. RESULTS: A total of 119 Swiss medical students were enrolled in our study. There was no statistically significant difference in the US assessment measurements, except for faster endpoint septal separation (EPSS) vascular setup time in the handheld group (P=0.001). There was no statistically significant difference in participants' perceived difficulty of US learning (P=0.198), comfort level (P=0.188), or self-estimated capability to perform US in the future (P=0.442). There was no statistically significant difference in the percentage of correctly obtained images (P=0.211) or images that were clinically useful (P=0.256). The median quality score of images obtained by the standard group was eight compared to seven in handheld group (P<0.01). CONCLUSION: Our data suggest a handheld US machine can perform as well as a standard US machine as an educational tool despite sacrifices in image quality.

A Case Report of Epiglottitis in an Adult Patient.

Epiglottitis is historically known to be a disease of childhood. However, since the implementation of the Haemophilus influenzae type B vaccination, there has been an increasing incidence within the adult population. This is a case report of a 36-year-old male who presented to the emergency department (ED) in severe respiratory distress with complaints of a sore throat, shortness of breath, odynophagia, dysphagia, and hoarseness. Physical exam revealed biphasic stridor, tachycardia, tachypnea, and an erythematous uvula. Imaging of his neck revealed findings consistent with epiglottitis containing nonspecific air. The patient was rapidly intubated, started on broad spectrum antibiotics and dexamethasone. He was admitted for intensive medical management with Otolaryngology consultation. This case report highlights the importance of rapid recognition and diagnosis of epiglottitis in an adult population to prevent morbidity and mortality. Topics: Epiglottitis, stridor, odynophagia, dysphagia, Haemophilus influenzae, group C streptococci, thumb-print sign, intubation.

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection requiring prompt diagnosis and immediate surgical debridement. Imaging, including a computed tomography (CT) scan, can often aid in the diagnosis, though it can prolong time to treatment and diagnosis. Point-of-care ultrasound (POCUS) is often used in the ED to identify soft tissue infections. The objective of this study is to evaluate the use of POCUS to identify NF in patients presenting to the emergency department. METHODS: We prospectively enrolled patients who presented to the emergency department (ED) with suspected soft tissue infection who received a computed tomography and/or surgical consult. POCUS images of the suspected site of infection were obtained by the emergency medicine physician and interpreted based on sonographic findings of NF. These findings were compared with CT scan or surgical impression. RESULTS: We enrolled 64 patients in this study. Eight were determined to be at high risk of having NF based on CT scan and/or surgical impression. All of these patients also had POCUS images interpreted as concerning for NF. Furthermore, 56 patients were classified as being low risk for having NF based on CT scan and/or surgical impression. All but one of these patients had POCUS images interpreted as not concerning for NF. CONCLUSIONS: Our data indicates that POCUS can be used to identify NF with a high sensitivity and specificity.

Diagnosis of Bladder Diverticula with Point-of-Care Ultrasound.

CASE PRESENTATION: A 65-year-old male presented to the emergency department with symptoms including fever, abnormal urinalysis, and elevated post-void residual. Point-of-care ultrasound was used to rapidly diagnose a bladder diverticulum. The patient was subsequently seen by urology for outpatient bladder repair. DISCUSSION: Bladder diverticula, an out-pouching of the bladder, may occur congenitally or as a result of various bladder conditions and/or surgery. Although bladder diverticula are rare and often asymptomatic, severe complications including frequent recurring urinary tract infections may arise depending on the patient.

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound.

INTRODUCTION: Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN). CASE REPORT: A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with "dirty shadowing" within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation. CONCLUSION: Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.

A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care Ultrasound.

Point-of-Care Ultrasound (POCUS) is a rapidly growing means of accelerated diagnosis for various conditions. This case report demonstrates POCUS use to differentiate porcelain gallbladder (PGB) from wall-echo-shadow (WES) sign. A 75-year-old female presented for evaluation of elevated liver function tests (LFTs). Upon arrival, she had no acute complaints with unremarkable vital signs, aside from elevated blood pressure of 155/79 mmHg. Review of LFTs demonstrated elevation of total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). Physical examination and review of systems were unremarkable. POCUS revealed common bile duct dilatation with cholelithiasis and sludge. While these findings may be confused with a WES sign, POCUS also revealed a hyperechoic gallbladder wall (GBW) with shadowing and irregular clumps of echo. The hyperechoic GBW with irregular shadowing heightened the suspicion for PGB. Computed tomography scan confirmed the presence of PGB. The patient had a stent placed near the common hepatic duct stricture and was advised to return for cholecystectomy. She was readmitted three months later due to bacteremia, likely caused by gallbladder obstruction in the setting of gallbladder cancer. Point of care ultrasound can be used to identify PGB. Because PGB has been associated with gallbladder carcinoma, prompt diagnosis is vital in early and aggressive treatment. In this case report, we demonstrate a reliable method in properly diagnosing PGB through POCUS. Topics: Point-of-care ultrasound, ultrasound, porcelain gallbladder, WES sign, wall-echo-shadow sign.

Point-of-care Ultrasound in the Evaluation of Mitral Valve Regurgitation and Mitral Annular Calcification.

CASE PRESENTATION: A 77-year-old female presented to the emergency department (ED) with chest pain. Cardiac point-of-care ultrasound (POCUS) was performed and demonstrated a hyperechoic structure on the posterior leaflet of the mitral valve. Admission to cardiology and echocardiogram revealed moderately decreased mobility of the posterior leaflet, mitral annular calcification, and severe mitral regurgitation. DISCUSSION: These findings highlight the role of POCUS in identifying mitral valve pathology in the ED, ultimately leading to appropriate disposition and management. Mitral annular calcification can lead to significant manifestations including mitral stenosis or regurgitation, and advanced cases have been associated with an increased risk of infective endocarditis, thrombosis, and arrhythmia.

Point-of-care Ultrasound Detection of Cataract in a Patient with Vision Loss: A Case Report.

BACKGROUND: Point-of-care ocular ultrasound in the emergency department (ED) is an effective tool for promptly evaluating for several vision-threatening etiologies and can be used to identify more slowly progressing etiologies as well, such as cataract formation within the lens. CASE REPORT: A 62-year-old female presented to the ED with a two-day history of painless vision loss of the left eye as well as reduced vision for the prior 30 days. CONCLUSION: Point-of-care ultrasound was performed and showed calcification of the lens consistent with cataract.

A Case Report on Paget-Schroetter Syndrome Presenting as Acute Localized Rhabdomyolysis.

INTRODUCTION: The life- or limb-threatening differential diagnosis for upper extremity swelling can include deep vein thrombosis (DVT), infectious processes, and compartment syndrome. Chronic anatomic abnormalities such as axillary vein stenosis are rarely a consideration in the emergency department. CASE REPORT: We present a 26-year-old female with history of Chiari type 1 malformation who presented with acute left arm swelling. Initial workup, including point-of-care ultrasound, revealed the presence of significant soft tissue swelling without evidence of DVT. CONCLUSION: Further workup revealed an early, localized rhabdomyolysis secondary to axillary vein stenosis or venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome.

Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock.

INTRODUCTION: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. METHODS: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. RESULTS: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. CONCLUSION: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center.

BACKGROUND: Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients. METHODS: This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was cross-referenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented. RESULTS: We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient's chart although an eFAST was recorded and reviewed during ultrasound quality assurance. CONCLUSION: A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

The association of smoking with ultrasound-measured kidney dimensions
.

PURPOSE: Ultrasound is considered a preferred first-line imaging technique for the assessment of kidney function. The potential relationship between tobacco smoke exposure and ultrasound-measured renal characteristics has yet to be explored. We hypothesized that exposure to tobacco smoke would be associated with reduced kidney dimensions. MATERIALS AND METHODS: This was a cross-sectional study that included all individuals over age 18 at a single site in Mojokerto, Indonesia. A questionnaire was used to assess prior history and environmental exposure, and blinded evaluators performed ultrasound assessments. Six kidney parameters (length, width, and parenchymal thickness of each kidney) were considered as dependent variables, and statistical relationships were assessed using multivariate analysis. Echogenicity was evaluated using a 5-point grading scale described previously. RESULTS: Of the 445 participants assessed, a total of 138 male and 269 female subjects were included in the final analysis. There was a statistically significant association between kidney measures and the following independent variables: pack years smoking (p < 0.001), height (p < 0.001), weight (p < 0.001), and beginning to smoke at the age of 25 or younger (p < 0.001). There was not a statistically significant association between kidney measures and hypertension (p > 0.05) or diabetes (p > 0.05). Echogenicity was similar among all smoking groups. CONCLUSION: Kidney dimensions were decreased in individuals with increased smoking history. This association is notable, particularly given that statistically significant associations were not observed between renal dimensions and hypertension or diabetes. The null findings using echogenicity are consistent with previous studies.

Evaluation of a point-of-care ultrasound curriculum taught by medical students for physicians, nurses, and midwives in rural Indonesia.

PURPOSE: In the Indonesian health-care system, nurses and midwives often serve as the primary health-care providers due to physician shortages. Seeking to address the need for medical care in resource-limited environments, some have advocated for portable equipment in the hands of health-care providers. We hypothesized that medical students are able to effectively teach point-of-care ultrasound (POCUS) to physicians, nurses, and midwives in rural Indonesia. METHODS: We conducted a prospective, observational study using health-care practitioners from a clinic and accredited school for nursing and midwifery in Mojokerto, East Java, Indonesia. Enrolled practitioners took part in a 4-week POCUS course followed by postinstructional testing. RESULTS: A total of 55 health-care practitioners completed the course. This included 19 physicians, 13 nurses, and 19 midwives. Of the 55 clinicians, 43 (72%) passed the course and 12 (28%) failed. CONCLUSIONS: Physicians, nurses, and midwives in rural Indonesia showed significant acquisition of ultrasound (US) knowledge and skills following a 4-week US course. Following training, all three groups displayed skills in practical US use during a postcourse practical examination. This is one of the first studies to assess the efficacy of medical students teaching POCUS to midwives and nurses.

Evaluation of a Standardized Cardiac Athletic Screening for National Collegiate Athletic Association (NCAA) Athletes.

INTRODUCTION: Sudden cardiac death is a rare cause of death in young athletes. Current screening techniques include history and physical exam (H and P), with or without an electrocardiogram (ECG). Adding point of care cardiac ultrasound has demonstrated benefits, but there is limited data about implementing this technology. We evaluated the feasibility of adding ultrasound to preparticipation screening for collegiate athletes. METHODS: We prospectively enrolled 42 collegiate athletes randomly selected from several sports. All athletes were screened using a 14-point H and P based on 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, ECG, and cardiac ultrasound. RESULTS: We screened 11 female and 31 male athletes. On ultrasound, male athletes demonstrated significantly larger interventricular septal wall thickness (p = 0.002), posterior wall thickness (p <0.001) and aortic root breadth (p = 0.002) compared to females. Based on H and P and ECGs alone and a combination of H and P with ECG, no athletes demonstrated a positive screening for cardiac abnormalities. However, with combined H and P, ECG, and cardiac ultrasound, one athlete demonstrated positive findings. CONCLUSIONS: We believe that adding point of care ultrasound to the preparticipation exam of college athletes is feasible. This workflow may provide a model for athletic departments' screening.

A Prospective Evaluation of Point of Care Ultrasound Teaching in Switzerland.

CONTEXT: As the utility of point-of-care ultrasound (POCUS) continues to expand in the medical field, there is a need for effective educational methods. In Switzerland, medical education follows the European model and lasts 6 years, focusing on preclinical training during the first 2 years. No previous studies have evaluated the optimal time for teaching ultrasound in European medical education. AIMS: The aim of this study is to provide ultrasound training to medical students in Switzerland at varying times during their clinical training to determine if the level of training plays a role in their ability to comprehend and to apply basic POCUS skills. METHODS: We performed an observational study utilizing a convenience sample of Swiss medical students between July 11, 2016 and August 6, 2016. They were taught a 2-day POCUS course by five American-trained 1st-year medical students. Following this course, students were evaluated with written and clinical examination. RESULTS: 100 Swiss medical students were enrolled in the study. A total of 59 of these students were early clinical students, and 41 students were late clinical students. A two-tailed t-test was performed and demonstrated that the late clinical students performed better than the early clinical students on the written assessment; however, no difference was found in clinical skill. CONCLUSION: Our data suggest that Swiss medical students can learn and perform POCUS after a 2-day instructional taught by trained 1st-year American medical students. No difference was found between students in early clinical training and late clinical training for the ability to perform POCUS.