Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women.

INTRODUCTION: Rapid and accurate determination of gestational age may be vital to the appropriate care of the critically ill pregnant patient. Before the use of emergency ultrasound, physical examination of fundal height (FH) in the nonverbal patient was considered the quickest method to estimate gestational age. We conducted a prospective, observational study of the performance of bedside sonography to determine gestational age. METHODS: We enrolled a convenience sample of women in their second or third trimester of pregnancy. Emergency physicians (EPs) made ultrasound measurements of fetal biparietal diameter (BPD) and femur length, followed by a measurement of FH. These measurements were compared with true gestational age (TGA), sonography by an ultrasound technician, and measurement of FH performed by an obstetrician. Main outcome measures were the average time needed to complete measurements; correlation coefficients between EP measurements and those made by an ultrasound technician, an obstetrician, and TGA, and overall accuracy to determine fetal age greater than 24 weeks. RESULTS: The average time to complete ultrasound measurements was less than 1 minute. When physician-performed measurements were compared with TGA, the correlation coefficients were 0.947 (0.926-0.968) for BPD, 0.957 (0.941-0.973) for femur length, and 0.712 (0.615-0.809) for FH. When determining fetal viability, EP's overall accuracy was 96% using ultrasound and 80% using FH. CONCLUSIONS: With brief training, EPs can quickly and accurately determine gestational age using ultrasound, and these estimates may be more accurate than those obtained through physical examination. Emergency physicians should consider using ultrasound in emergent evaluation of pregnant patients who are unable to provide history.

Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial.

STUDY OBJECTIVE: We seek to compare ultrasonographically guided peripheral intravenous access to a non-ultrasonographically guided method in a randomized trial of emergency department patients with difficult intravenous access. METHODS: A prospective cohort of patients with difficult intravenous access was established. Patients were randomized to 2 groups: (1) intravenous access obtained through an ultrasonographically guided technique or (2) intravenous access obtained through non-ultrasonographically guided methods. Outcomes measured were number of attempts after enrollment, time to cannulation from enrollment, and patient satisfaction. Groups were compared with nonparametric analysis. RESULTS: Fifty-nine patients were randomized. Twenty-eight patients were randomized to the ultrasonography group and 31 to the no ultrasonography group. A median of 2 further intravenous attempts was required in each group before successful cannulation, corresponding to a difference of 0 attempts (95% confidence interval [CI] 0 to 1 attempts). Time to cannulation showed a median of 39 minutes in the ultrasonography group compared with 26 minutes for the no ultrasonography group, giving a median increase of 13 minutes for the ultrasonographically guided group (95% CI -5 to 28 minutes). Patients in the ultrasonography group had a median Likert satisfaction score of 8 compared with 7 for the no ultrasonography group, giving a median increase of 1 on this scale in the ultrasonography group (95% CI 0 to 2). CONCLUSION: Ultrasonographically guided peripheral intravenous cannulation did not decrease the number of attempts or the time to successful catheterization, nor did it improve patient satisfaction compared with the group that did not use ultrasonography. Superiority of ultrasonographically guided peripheral intravenous cannulation is not supported by this study.

A survey of bedside ultrasound use by emergency physicians in California.

OBJECTIVE: The purpose of this study was to investigate the current practice of emergency physician-performed bedside ultrasound examinations in California and to assess differences between academic and community practice. METHODS: We queried all emergency departments (EDs) in California to determine whether bedside ultrasound was used by emergency physicians. Among EDs that were using bedside ultrasound, we administered a survey to assess use patterns, credentialing criteria, and quality assurance (QA) programs. RESULTS: We contacted all eligible EDs (n = 293) by telephone and had a 100% response rate for our primary question: 101 EDs (34%) reported use of bedside ultrasound. Of these 101 EDs, 97 (96%) responded to the secondary survey, showing the following: (1) 48% of physicians at each site were credentialed to use ultrasound in at least 1 modality; (2) 70% of EDs used American College of Emergency Physicians (ACEP) criteria for credentialing guidelines; and (3) 33% had an ultrasound QA program. Comparing practice settings, 68% of academic departments used bedside ultrasound compared with 29% of community departments (difference, 39%; 95% confidence interval [CI], 23% to 54%; P < .0001). In academic departments, a mean of 60% of physicians were credentialed, compared with 41% in community EDs (difference, 19%; 95% CI, 2.5% to 35%; P = .036). CONCLUSIONS: Most California EDs do not use bedside ultrasound. Although most EDs using ultrasound report that they follow ACEP emergency ultrasound guidelines, most do not have a QA program as recommended by these guidelines. Compared with community EDs, academic EDs are more likely to use bedside ultrasound, have physicians credentialed in ultrasound use, and have QA programs.