Sonographic inferior vena cava measurements to assess hydration status in college football players during preseason camp.

OBJECTIVES: The purpose of this study was to determine whether sonographic measurement of the inferior vena cava (IVC) in college football players during preseason camp is a reliable way to detect and monitor dehydration. Our primary hypothesis was that IVC diameter measurements, the postpractice caval index, and expiratory diameter were significantly related to percent weight loss after a preseason football practice. METHODS: A prospective cohort sample of Division I intercollegiate football players in preseason training camp was recruited before practice. All football players on the active roster who were at least 18 years of age were eligible to participate in the study. Sonographic IVC measurements were obtained in the long axis using either the subcostal or subxiphoid approach during inspiration and expiration both before and after an approximately 3-hour practice with moderate to high levels of exertion at high ambient temperatures. Player weights were recorded in the locker room before and after practice. RESULTS: A total of 27 prepractice and postpractice sonographic measurements were obtained. The postpractice expiratory IVC diameter was significantly related to percent weight loss after practice (R(2) = 0.153; P = .042), with the IVC diameter being significantly inversely correlated with percent weight loss; the regression coefficient was -1.07 (95% confidence interval, -2.09 to -0.04). There was no statistically significant relationship between percent weight loss and the postpractice caval index; the regression coefficient was 0.245 (95% confidence interval, -0.10 to 0.59; R(2) = 0.078; P = .16). CONCLUSIONS: The postpractice expiratory IVC diameter was significantly related to percent weight loss after practice, whereas the caval index was not found to correlate with weight loss.

Focused Assessment With Sonography for Trauma Examination: Reexamining the Importance of the Left Upper Quadrant View.

OBJECTIVES: The purpose of this study was to determine the frequency and predominant location of isolated free fluid in the left upper quadrant (LUQ) on focused assessment with sonography for trauma (FAST) examinations of adult patients with trauma presenting to the emergency department. METHODS: We conducted a retrospective review of adult patients with positive FAST results for free fluid in the abdomen at 2 academic emergency departments. Eligible FAST examinations were reviewed for the presence of fluid in the LUQ and exact location of free fluid within the LUQ. RESULTS: A total of 100 FAST examinations with free fluid in the abdomen that met inclusion criteria were identified during the study period. Overall 32 of 100 (32%; 95% confidence interval [CI], 23.5%-41.6%) of patients with positive FAST results were found to have free fluid in the LUQ. Only 6 of 100 (6%; 95% CI, 2.5%-11.9%) patients with positive FAST results had free fluid isolated to the LUQ. Of these 6 patients with isolated LUQ free fluid, none had free fluid isolated to the splenorenal fossa alone; 1 had free fluid isolated to the subphrenic space (above the spleen/below the diaphragm); and 4 had free fluid visible only in the left paracolic gutter/inferior to the spleen. Twenty-seven of 32 patients (84%; 95% CI, 69.1%-93.8%) with free fluid anywhere in the LUQ were also found to have fluid in the left paracolic gutter. CONCLUSIONS: Free fluid isolated to the LUQ occurs in a clinically significant number of adult patients with trauma and positive FAST results. Isolated fluid accumulation was often seen within the left paracolic gutter.

A comparison of the prehospital motor component of the Glasgow coma scale (mGCS) to the prehospital total GCS (tGCS) as a prehospital risk adjustment measure for trauma patients.

OBJECTIVE: This study compared the prehospital motor component subscale of the Glasgow Coma Scale (mGCS) to the prehospital total GCS (tGCS) score for its ability to predict the need for intubation, survival to hospital discharge, and neurosurgical intervention in trauma patients. METHODS: This is a retrospective analysis of an urban level 1 trauma registry. All trauma patients presenting to the trauma center emergency department via emergency medical services from July 2008 through June 2010 were included. The area under the receiver operating characteristics curve (AUC) analysis was used to compare the predictive ability of the prehospital mGCS to tGCS for three outcomes: intubation, survival to hospital discharge, and neurosurgical intervention. Two subgroups (patients with injury severity score [ISS] ≥ 16 and traumatic brain injury [TBI] [head abbreviated injury score (AIS) ≥ 3]) were analyzed. An a priori statistically significant absolute difference of 0.050 in AUC between mGCS and tGCS for these clinical outcomes was used as a clinically significant difference. Multiple imputation was used for missing prehospital GCS data. RESULTS: There were 9,816 patients, of which 4% were intubated, 3.8% had neurosurgical intervention, and 97.1% survived to hospital discharge. The absolute difference in AUC (prehospital tGCS minus mGCS) for all cases was statistically significant for all three outcomes but did not reach the clinical significance threshold: survival = 0.010 (95% CI: 0.002-0.018), intubation = 0.018 (95% CI: 0.011-0.024), and neurosurgical intervention = 0.019 (95% CI: 0.007-0.029). The difference in AUC between tGCS and mGCS for the subgroups ISS ≥ 16 (n = 1,151) and TBI (n = 1,165) did not reach clinical significance for the three outcomes. The discriminatory ability of the prehospital mGCS was good for survival (AUC: all patients = 0.89, ISS ≥ 16 = 0.84, traumatic brain injury = 0.86) excellent for intubation (AUC: all patients = 0.95, ISS ≥ 16 = 0.91, traumatic brain injury = 0.91), and poor for neurosurgical intervention (AUC: all patients = 0.67, ISS ≥ 16 = 0.57, traumatic brain injury = 0.60). CONCLUSION: The prehospital mGCS appears have good discriminatory power and is equivalent to the prehospital tGCS for predicting intubation and survival to hospital discharge in this trauma population as a whole, those with ISS ≥ 16, or TBI.

Ability of emergency physicians with advanced echocardiographic experience at a single center to identify complex echocardiographic abnormalities.

OBJECTIVES: To determine the ability of emergency physicians to detect complex abnormalities on point-of-care (POC) echocardiograms. METHODS: Single-blinded, nonrandomized, cross-sectional study. Twenty-five different emergency medicine clinical scenarios (video clips and digital images) covering a variety of echocardiographic abnormalities were presented to a group of emergency physician sonologists. The echocardiographic abnormalities included right ventricular dysfunction, left ventricular systolic dysfunction, diastolic dysfunction, regional wall motion abnormalities, Doppler abnormalities of pericardial tamponade physiology, left ventricular hypertrophy, hypertrophic cardiomyopathy, and aortic abnormalities. All emergency physician sonologists were blinded to the study hypothesis. They reviewed echocardiography video clips and images individually, and their interpretations were compared with the criterion standard (expert echocardiographer interpretations). RESULTS: A total of 200 echocardiography studies (video clips and images) were independently reviewed by 8 emergency physician sonologists with varying POC echocardiography experiences. Emergency physicians accurately identified left ventricular systolic dysfunction 94% of the time, diastolic dysfunction (100%), and right ventricular dysfunction 80% of the time. Regional wall motion abnormalities were detected only 50% of the time. Doppler echocardiographic abnormalities of pericardial tamponade physiology were accurately identified 57% of the time. Emergency physicians who performed more than 250 POC echocardiograms were found to be more accurate in identifying complex echocardiographic abnormalities. CONCLUSIONS: Our study results suggest that with increased experience, emergency physicians can accurately identify most of complex echocardiographic abnormalities.

Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact.

OBJECTIVES: The aim of this study was to determine the fiscal impact of implementation of a novel emergency department (ED) point-of-care (POC) ultrasound billing and reimbursement program. METHODS: This was a single-center retrospective study at an academic medical center. A novel POC ultrasound billing protocol was implemented using the Q-path Web-based image archival system. Patient care ultrasound examination reports were completed and signed electronically online by faculty using Q-path. A notification was automatically sent to ED coders from Q-path to bill the scans. ED coders billed the professional fees for scans on a daily basis and also notified hospital coders to bill for facility fees. A fiscal analysis was performed at the end of the year after implementing the new billing protocol, and a before-and-after comparison was conducted. RESULTS: After implementation of the new billing program, there was a 45% increase in the ED faculty participation in billing for patient care examinations (30%-75%). The number of ultrasound examinations billed increased 5.1-fold (4449 vs 857) during the post implementation period. The total units billed increased from previous year for professional services to 4157 from 649 and facility services to 3266 from 516. During the post implementation period, the facility fees revenue increased 7-fold and professional fees revenue increased 6.34-fold. After deducting the capital costs and ongoing operational costs from approximate collections, the net profits gained by our ED ultrasound program was approximately $350000. CONCLUSIONS: Within 1 year of inception, our novel POC ultrasound billing and reimbursement program generated significant revenue through ultrasound billing.

A novel gelatinized barium sulfate injection method for assessment of bronchoalveolar lavage parameters.

INTRODUCTION: Bronchoalveolar lavage (BAL) is frequently used in pulmonary medicine though it requires further optimization. Practical obstacles such as patient safety and procedural limitation have to date precluded large, controlled trials aimed at standardization of BAL procedure. Indeed, BAL guidelines are based on observational data. Innovative research methods are necessary to advance the clinical practice of BAL. METHODS: In our study, we evaluated the effect of injecting a gelatinized barium solution into different lobes and segments of cadaveric lungs. As the technique requires an irreversible injection into lung airspaces, it is not suitable for in vivo purposes. We measured the volume returned from BAL as well as the distribution of BAL injection via dissection. Segmental anatomic orientation was compared to a radiologist's impression of plain film radiographs taken of injected lungs. RESULTS: Mean injected volume distributions were greatest in the upper lobes and lowest in the lower lobes; mean ratios of injected volume distribution to lung lobe volume also followed this trend. Cannulated bronchi orders favored lower branches in the upper lobe and higher branches in the lower lobes. Segmental anatomy varied by the lung lobe injected and was most varied in the lower lobes. CONCLUSION: This novel gelatinized-barium injection technique provides a minimally complex method to yield clinically meaningful feedback on the performance of BAL. The technique is also adaptable to study of procedural parameters in the context of variable lung anatomies and pathologies.

Can emergency physicians perform common carotid Doppler flow measurements to assess volume responsiveness?

INTRODUCTION: Common carotid flow measurements may be clinically useful to determine volume responsiveness. The objective of this study was to assess the ability of emergency physicians (EP) to obtain sonographic images and measurements of the common carotid artery velocity time integral (VTi) for potential use in assessing volume responsiveness in the clinical setting. METHODS: In this prospective observational study, we showed a five-minute instructional video demonstrating a technique to obtain common carotid ultrasound images and measure the common carotid VTi to emergency medicine (EM) residents. Participants were then asked to image the common carotid artery and obtain VTi measurements. Expert sonographers observed participants imaging in real time and recorded their performance on nine performance measures. An expert sonographer graded image quality. Participants were timed and answered questions regarding ease of examination and their confidence in obtaining the images. RESULTS: A total of 30 EM residents participated in this study and each performed the examination twice. Average time required to complete one examination was 2.9 minutes (95% CI [2.4-3.4 min]). Participants successfully completed all performance measures greater than 75% of the time, with the exception of obtaining measurements during systole, which was completed in 65% of examinations. Median resident overall confidence in accurately performing carotid VTi measurements was 3 (on a scale of 1 [not confident] to 5 [confident]). CONCLUSION: EM residents at our institution learned the technique for obtaining common carotid artery Doppler flow measurements after viewing a brief instructional video. When assessed at performing this examination, they completed several performance measures with greater than 75% success. No differences were found between novice and experienced groups.

Theme-based teaching of point-of-care ultrasound in undergraduate medical education.

A handful of medical schools have developed formal curricula to teach medical students point-of-care ultrasound; however, no ideal method has been proposed. The purpose of this study was to assess an innovative theme-based ultrasound educational model for undergraduate medical education. This was a single-center cross-sectional study conducted at an academic medical center. The study participants were 95 medical students with minimal or no ultrasound experience during their third year of training. The educational theme for the ultrasound session was "The evaluation of patients involved in motor vehicle collisions." This educational theme was carried out during all components of the 1-day event called SonoCamp: asynchronous learning, the didactic lecture, the skills stations, the team case challenge and the individual challenge stations. Assessment consisted of a questionnaire, team case challenge, and individual challenges. A total of 89 of 95 (94 %) students who participated in SonoCamp responded, and 92 % (87 of 95) completed the entire questionnaire before and after the completion of SonoCamp. Ninety-nine percent (95 % CI, 97-100 %) agreed that training at skill stations helped solidify understanding of point-of-care ultrasound. Ninety-two percent (95 % CI, 86-98 %) agreed that theme-based learning is an engaging learning style for point-of-care ultrasound. All students agreed that having a team exercise is an engaging way to learn point-of-care ultrasound; and of the 16 groups, the average score on the case-based questions was 82 % (SD + 28). The 1-day, theme-based ultrasound educational event was an engaging learning technique at our institution which lacks undergraduate medical education ultrasound curriculum.