Impact of an enhanced focused cardiac ultrasound on treatment changes in a population of internal medicine patients.

BACKGROUND: Hospitalized patients with acute shortness of breath (SOB) could benefit from an enhanced focused cardiac ultrasound (eFoCUS) with Doppler measurements to reassess treatment and diagnosis. METHODS: This was a retrospective observational study performed in a medical ward. Included patients were those hospitalized for acute SOB. The objectives were to assess therapeutic and diagnosis changes associated with eFoCUS. The primary endpoint of the analysis was a composite of introduction or discontinuation of diuretics, antibiotics or anticoagulation following eFoCUS. RESULTS: Between January 2018 and July 2021, 119 patients were included, 67 women and 52 men, mean age 84 ± 11 years old. The eFoCUS was performed within a median time of 55 h (1st-3rd IQ: 21-107) following hospital admission. Overall, eFoCUS was associated with a change in diagnostic in 40 patients (34% [CI 95%: 25%-43%], p < 10-4 ) and a change in treatment in 53 patients (45% [CI 95%: 35%-54%], p < 10-4 ). Diuretics were prescribed in 94 patients before eFoCUS and in 56 after (p = 10-4 ), antibiotics in 34 before and 27 after and anticoagulation in 30 before and 40 after. CONCLUSION: eFoCUS was associated with both therapeutic and diagnostic changes in patients with SOB. Such results should be confirmed in multicentric prospective studies.

Impact of Different Training Methods on Daily Use of Point-of-Care Ultrasound: Survey on 515 Physicians.

ABSTRACT: Point-of-care ultrasound (POCUS) curriculum varies among countries. However, the length of training required for physicians is still under debate. We investigated the impact of different training methods: short hands-on courses (STS), long academic training sessions (LTS), or both (mixed training [MTS]), for POCUS daily use and self-reported confidence overall and specific to specific clinical situations. This was a descriptive study conducted over a 3-month period through a Web-based survey designed to assess the influence of different methods of POCUS training among physicians and residents on their daily practice. The survey was sent to 1212 emergency physicians with prior POCUS training; 515 answers (42%) could be analyzed. Participants in the STS group performed POCUS less frequently than physicians in the LTS or MTS group. Daily use in the STS group was 51% versus 82% in the LTS group and 83% in the MTS group ( P < 0.01). The overall self-reported confidence in POCUS was lower in the STS group ( P < 0.01) in all studied clinical situations. There was no significant difference between LTS and MTS groups ( P > 0.05). Method of POCUS training significantly influenced POCUS daily use. Physicians who underwent long training sessions used POCUS more frequently in their routine practice and were significantly more confident in their ability to perform and interpret a POCUS examination.

Factors associated with tracheal intubation-related complications in the prehospital setting: a prospective multicentric cohort study.

Background Emergency tracheal intubation is routinely performed in the prehospital setting. Airway management in the prehospital setting has substantial challenges. Objective The aim of the present study was to determine risk factors predicting tracheal intubation-related complications on the prehospital field. Setting A prospective, multicentric, cohort study which was conducted in three mobile ICUs (MICUs; service mobile d'urgence et de réanimation).Outcome measures and analysis Tracheal intubation-related complications were defined as the occurrence of at least one of the following events: oxygen desaturation (SpO2 < 90%) during tracheal intubation, aspiration (regurgitation visualized during laryngoscopy), and vomiting. Difficult intubation was defined as more than two failed direct laryngoscopic attempts, or the need for any alternative tracheal intubation method. Multivariate logistic regressions were used. Results During the 5-year study period, 1915 consecutive patients were intubated in the MICUs participating in the study. Overall, 1287 (70%) patients were successfully intubated after the first laryngoscopic attempt, with rates of 90, 74, 42, and 30% for Cormack-Lehane grade 1, 2, 3, and 4, respectively. Tracheal intubation was difficult in 663 cases (36%). Tracheal intubation-related complications occurred in 267 (14%) patients. In the multivariate analysis, we found that the leading risk factors for tracheal intubation-related complications were Cormack and Lehane grade 3 and 4 [odds ratio (OR) = 1.65; 95% confidence interval (CI), 1.05-2.61; and OR = 2.79; 95% CI, 1.56-4.98, respectively], a BMI of more than 30 (OR = 1.61; 95% CI, 1.13-2.28), when intubation was difficult (OR = 1.72; 95% CI, 1.15-2.57), and when tracheal intubation required more than one operator (OR = 2.30; 95% CI, 1.50-3.49).Conclusions In this prospective study, we found that Cormack and Lehane more than grade 2, BMI >30, difficult intubation, and tracheal intubation requiring more than one operator were all independent predictors of tracheal intubation-related complications in the prehospital setting. When these risk factors are identified on scene, adapted algorithms that anticipate the use of a bougie should be generalized to reduce morbidity on the prehospital field.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) SHORT VERSION.

OBJECTIVE: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75 %. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION.

AIMS: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

Are seminal vesicles a potential pitfall during pelvic exploration using point-of-care ultrasound (POCUS)?

BACKGROUND: Trauma is a major cause of death among the working population. Many countries have now adopted a structured approach to trauma management in which ultrasound is used as a primary evaluation tool. While its use has direct therapeutic benefits, many artifacts and pitfalls are inherent to the technique. Knowledge of the most frequently encountered pitfalls in practice could thus help reduce the risk of error and lead to more accurate trauma assessments. OBJECTIVE: This study evaluates a potential pitfall caused by seminal vesicles during focused assessment with sonography for trauma examinations of the male pelvis performed by an emergency physician with experience in point-of-care ultrasound. METHODS: We took five static and five dynamic (3-s loops) transverse ultrasound images of the pelvis in five healthy males. The images and videos were then incorporated into an online survey and emailed through the World Interactive Network Focused On Critical UltraSound (WINFOCUS) in France and the Ultrasound and Emergency Medicine (UEM) Organization in Belgium. A questionnaire asked anonymous participants to assess the presence of free fluid in the static and dynamic images and to share information about their training and experience in point-of-care ultrasound. To validate the static and dynamic images, the survey was sent to three external radiologists for independent verification. RESULTS: A total of 191 individuals responded fully or partially to the survey, 114 of whom completed it. Among the 114 participants who completed the survey, the misinterpretation rate was 0.55 (95CI 0.51-0.60) for all static and dynamic ultrasound transverse pelvic views. The misinterpretation rate was 0.61 (95CI 0.55-0.66) and 0.50 (95CI 0.45-0.55) for static and dynamic ultrasound transverse pelvic views, respectively. The three external radiologists answered the questionnaire correctly without misinterpreting the survey ultrasound views. CONCLUSIONS: Seminal vesicles are a potential pitfall when interpreting transverse ultrasound images of the male pelvis in the context of point-of-care ultrasound.

Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study.

BACKGROUND AND IMPORTANCE: Early identification of the cause of shock is associated with better prognosis. OBJECTIVE: The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED). DESIGN, SETTINGS AND PARTICIPANTS: This was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items. INTERVENTION: echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia. OUTCOMES MEASURE AND ANALYSIS: We defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel. MAIN RESULTS: 85 patients [mean age of 73 (14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001). CONCLUSION: This study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.

Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.

BACKGROUND: Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France. METHODS: We analysed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital. RESULTS: From 2011 to 2018, 1854 UOHB were recorded, of whom 520 were analysed. We found that using incubator care was the most effective rewarming method (+ 0.8 °C during transport), followed by the combination of plastic bag, skin-to-skin and cap (+ 0.2 °C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+ 0.0 °C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator. We also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4 °C). CONCLUSIONS: Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature or initial hypothermia, using such a method would be preferred.

Evaluation of short training session for venous limited compression ultrasonography: prospective multicenter study.

BACKGROUND: Venous limited compression ultrasonography (VLCU) is recommended in case of suspicion of deep venous thrombosis (DVT). Current training pathways are rather long and include experiential phase. This aim of this study was to investigate the efficacy of a short training session for VLCU without experiential phase. The training session was applied in residents without previous ultrasound skills. Program included operation of ultrasound device and interpretation of venous images. Included patients were older than 18 years and had a suspicion of DVT. After realization of VLCU using usual technique, residents reported the dynamic compressibility of the femoral and popliteal veins, the presence or not of a visible thrombus, self-reported difficulty and duration. Patients then underwent a whole leg ultrasonography (WLCU) in the local laboratory which was blinded to VLCU results. The main criterion was the negative-predictive value (NPV) of VLCU for the absence of proximal DVT diagnosed with WLCU. Secondary criteria were VLCU diagnostic performances, rate of inability to conclude, difficulty and duration. For a NPV of 95 ± 6%, the needed number of patients was 96. This study was approved by the ethical committee. RESULTS: 102 patients were analyzed. 46 residents were trained. A DVT was diagnosed by WLCU in 18 patients (prevalence of 17.6% [95% CI 11-26%]). VLCU detected 15 DVT (NPV of 96% [95% CI 89-99%]). The positive likelihood ratio was 9.9, the negative likelihood ratio 0.19 and Cohen's Kappa 0.62 [95% CI 0.52-0.71]. The sensitivity was 83% [CI 95% 60-94%] and specificity 88% [CI 95% 79-93%]. The mean number of VLCU by residents was 2.3 ± 2.1, median 2 (minimum 1, maximum 8). Mean duration was 3.4 min, difficulty was 3.7 ± 2. CONCLUSION: The principal objective, NPV 96% [95% CI 89-99%], was achieved. However, this short training session was inadequate to allow ruling-out a DVT with sufficient security. Thus, the experiential phase seems to be essential.

Early point-of-care focused echocardiographic asystole as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: a study protocol for a prospective, multicentre observational study.

INTRODUCTION: Management of out-of-hospital cardiac arrests (OHCAs) in France is performed by a particular prehospital system based on medicalisation of mobile intensive care units composed of an emergency physician and a nurse with all the required devices for advanced care. It follows the European recommendations which advocate for the use of early point-of-care focused echocardiography (EPOCE) in the prehospital setting. An ability of EPOCE may be to predict the absence of return of spontaneous circulation (ROSC) in cases of absence of cardiac motion. We thus intended to investigate this predictive value with a prospective multicentre study. This paper describes the study protocol, while the first patients were recruited in December 2018. METHODS: ACE is a prospective multicentre (n=8) prognostic study. Briefly, as soon as OHCA is diagnosed and advanced life support (ALS) is initiated, EPOCE will be performed during the automated external defibrillator' analysis period. The physician will assess detectable motion within the heart and reversible causes of OHCA. However, as the prognostic value of absence of cardiac motion is not currently validated, the results of EPOCE will not be used to withdraw ALS, and the decision to withdraw life support will be done following the European Resuscitation Council recommendations during our study. ANALYSIS: The primary endpoint is the positive predictive value of absence of cardiac motion for the absence of final ROSC. The secondary endpoints are predictive characteristics of EPOCE asystole on morbimortality 30 days after OHCA, description of reversible cause and analysis of the EPOCE technique. ETHICS AND DISSEMINATION: ACE was approved by an ethical committee (2018-AO1491-54). While ACE is adapted to the French prehospital system, its results will be translatable to other organisations if inter-rater variability is not found. TRIAL REGISTRATION NUMBER: NCT03494153.

Response to letter to the editor: "comment on unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort".

The aim of this Letter to the Editor was to respond to a comment highlighting potential statistical biases in an analysis of our recently published article. We therefore specified the method for selecting the model variables in order to limit overfitting, then we used the Firth method to control the sparse data bias, and finally for checking internal validity we used bootstrapping methods. In total, the conclusions of our model were not changed by these new analyses.

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort.

BACKGROUND: In France, while most babies are delivered at hospital, emergency medical services (EMS) weekly manage calls for unplanned out-of-hospital births. The objective of our study was to describe neonatal morbidity and mortality, defined as death or neonatal intensive care unit hospitalization at Day 7, in a prospective multicentric cohort of unplanned out-of-hospital births. METHODS: We prospectively analyzed out-of-hospital births from 25 prehospital EMS units in France. The primary outcome was neonatal morbidity and mortality, and the secondary outcome was risk factors associated with neonatal morbidity and mortality. A univariate logistic regression was first made, followed by a multivariate logistic regression with backward selection. RESULTS: From October 2011 to August 2018, a total of 1670 unplanned out-of-hospital births were included. Of these, 1652 (99.2%) were singleton and 1537 (93.5%) had prenatal care. Maternal mean age of the study population was 30 ± 5.5 (range 15 to 48). The majority of women were multiparous, but 13% were nulliparous. Overall, 45.3% of these unplanned out-of-hospital births were medically-driven, either by phone during medical regulation (12.5%) or on scene by the prehospital emergency medical service units (32.9%). The prevalence of neonatal morbidity and mortality was 6.3% (n = 106) after an unplanned out-of-hospital birth (death before Day 7: n = 20; 1.2%). The multivariate logistic regression found that multiparity (adjusted Odds Ratio = 70.7 [4.7-1062]), prematurity (adjusted Odds Ratio = 6.7 [2.1-21.4]), maternal pathology (adjusted Odds Ratio = 2.8 [1.0-7.5]) and hypothermia (adjusted Odds Ratio = 2.8 [1.1-7.6]) were independent predictive factors of neonatal morbidity and mortality. CONCLUSIONS: Our study assessed for the first time risk factors for adverse perinatal outcome in a large and multicenter cohort of unplanned out-of-hospital births. We have to improve temperature management in the out-of-hospital field and future trials are required to investigate strategies to optimize newborns management in the prehospital area.

Acute fissuration of a giant splenic artery aneurysm detected by point-of-care ultrasound: case report.

BACKGROUND: Epigastric pain is frequent in Emergency Medicine and remains a challenging situation. Besides benign etiologies such as gastritis or uncomplicated cholelithiasis, it could reveal myocardial infarction or vascular disease. Point-of-care ultrasound (POCUS) could be performed in such situation. CASE PRESENTATION: A healthy 66-year-old man with no previous medical history was admitted to the Emergency Department for a rapid onset epigastric pain. He reported taking non-steroidal anti-inflammatories for 1 week prior to admission. His pain had rapidly subsided and the physical examination was inconclusive. ECG and blood samples were normal. POCUS revealed a vascular mass located between the spleen and the left kidney measuring 80 * 74 mm associated with small amounts of free peritoneal fluid. Computed tomography diagnosed a fissurated giant aneurysm of the splenic artery. The aneurysm was managed emergently by endovascular exclusion by selective splenic artery embolization. The post-intervention course was uneventful and the patient was discharged home 3 days later. The patient has remained free from any complications of the embolization 6 months after the procedure. CONCLUSION: Spontaneously regressive epigastric pain with a normal physical and biology/ECG should not necessarily reassure the physician, in particular if patients have cardiovascular risk factors. A POCUS should be considered for these patients.

Evaluation of a short formation on the performance of point-of-care renal ultrasound performed by physicians without previous ultrasound skills: prospective observational study.

BACKGROUND: Point-of-Care Ultrasound (PoCUS) is recommended by emergency medicine societies for the detection of hydronephrosis. Training of certified Emergency Physicians (EP) without prior ultrasound experience remains debated. We investigate performance of a brief training session for the detection of hydronephrosis with PoCUS performed by EP without previous ultrasound experience. PATIENTS AND METHODS: This was a prospective observational study of a convenience sample of patients older than 18 years with presumed renal colic, acute pyelonephritis or documented acute renal failure. Exclusion criteria were pregnancy and documented end of life.After inclusion and informed consent, a PoCUS was performed. A radiologist's renal ultrasound (RRUS) was then conducted, the radiologist being blind to PoCUS result.The objective was to determine the diagnostic performance of PoCUS performed by EP for the detection of hydronephrosis using RRUS as gold standard. RESULTS: Six EP participated in this study. 55 patients were included, five secondary excluded for lack of RRUS. Age was 47 ± 22 years, sex ratio 1. Hydronephrosis prevalence was 38% (CI 95% [26-52%]). Sensitivity of PoCUS was 100% (CI 95% [82-100%]) while its specificity was 71% (CI 95% [52-86%]) with a NPV of 100% (CI 95% [85-100%]) and a 68% (CI 95% [48-84%]) PPV. Kappa coefficient was 0.65 (CI 95% [0.45-0.85]). DISCUSSION: We demonstrated that a short training program enables EP without previous ultrasound skills to rule out hydronephrosis with satisfactory performances. The main limitation was the absence of collection of the number of PoCUS by EP. After this didactic course, an experiential phase must be carried out.

Transcranial Doppler to Predict Neurologic Outcome after Mild to Moderate Traumatic Brain Injury.

BACKGROUND: To assess the performance of transcranial Doppler (TCD) in predicting neurologic worsening after mild to moderate traumatic brain injury. METHODS: The authors conducted a prospective observational study across 17 sites. TCD was performed upon admission in 356 patients (Glasgow Coma Score [GCS], 9 to 15) with mild lesions on cerebral computed tomography scan. Normal TCD was defined as a pulsatility index of less than 1.25 and diastolic blood flow velocity higher than 25 cm/s in the two middle cerebral arteries. The primary endpoint was secondary neurologic deterioration on day 7. RESULTS: Twenty patients (6%) developed secondary neurologic deterioration within the first posttraumatic week. TCD thresholds had 80% sensitivity (95% CI, 56 to 94%) and 79% specificity (95% CI, 74 to 83%) to predict neurologic worsening. The negative predictive values and positive predictive values of TCD were 98% (95% CI, 96 to 100%) and 18% (95% CI, 11to 28%), respectively. In patients with minor traumatic brain injury (GCS, 14 to 15), the sensitivity and specificity of TCD were 91% (95% CI, 59 to 100%) and 80% (95% CI, 75 to 85%), respectively. The area under the receiver operating characteristic curve of a multivariate predictive model including age and GCS was significantly improved with the adjunction of TCD. Patients with abnormal TCD on admission (n = 86 patients) showed a more altered score for the disability rating scale on day 28 compared to those with normal TCD (n = 257 patients). CONCLUSIONS: TCD measurements upon admission may provide additional information about neurologic outcome after mild to moderate traumatic brain injury. This technique could be useful for in-hospital triage in this context. (Anesthesiology 2016; 125:346-54).

Noninvasive ventilation use in French out-of-hospital settings: a preliminary national survey.

OBJECTIVE: The objective of our study was to describe noninvasive ventilation (NIV) practices (pressure support ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensive care units (SMUR) and their compliance with national consensus guidelines. METHOD: Online inquiry into practices of NIV among managers of French SMUR. Analyzed data include types of NIV devices and use of NIV. RESULTS: Upon 218 SMUR referenced within the SAMU de France database, 118 questionnaires (54%) were processed. Noninvasive ventilation equipment: 91% of the SMUR with at least one type of NIV device (continuous positive airway pressure only=82%; pressure support ventilation only=59%; both=50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonary edema, practices were compliant with recommendations in 80% of cases, although there was still room for improvement. For other pathologies, practices were very heterogeneous, not always properly assessed, and frequently not compliant with recommendations. CONCLUSION: To conclude, NIV use in the out-of-hospital setting in France seems to meet current recommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could be improved by the use of written procedures, conduction of further studies, and promotion of compliance through education.