Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip.

BACKGROUND: Safety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. METHODS: We investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. RESULTS: The procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. CONCLUSIONS: This study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Evaluation of esophageal injuries after defibrillation with transesophageal ultrasound probe in the mid-esophagus in pigs.

OBJECTIVE: Transesophageal echocardiography (TEE) is becoming increasingly utilized by emergency medicine providers during cardiac arrest. Intra-arrest, TEE confers several benefits including shorter pauses in chest compressions and direct visualization of cardiac compressions. Many ultrasound probe manufacturers recommend against performing defibrillation with the TEE probe in the mid-esophagus for fear of causing esophageal injury or damage to the probe, however no literature exists that has investigated this concern. To assess this, we performed cardiopulmonary resuscitation (CPR) and multiple defibrillations in 8 swine with a TEE probe in place. METHODS: We performed TEE on 8 adult swine during CPR and performed multiple 200 J defibrillations with the TEE probe in the mid-esophagus. Post-mortem, esophagi were dissected and inspected for evidence of injury. RESULTS: On macroscopic inspection of 8 esophagi, no evidence of hematoma, thermal injury, or perforation was noted. CONCLUSION: Our study suggests that performing defibrillation during CPR with a TEE probe in place in the mid-esophagus is likely safe and low risk for significant esophageal injury. This further bolsters the use of TEE in CPR and would enable continuous visualization of cardiac activity without the need to remove the TEE probe for defibrillation.

POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation.

OBJECTIVES: Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure. METHODS: We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure. RESULTS: Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually. CONCLUSION: If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.

Morel-Lavallée Lesion Diagnosed by Point-of-Care Ultrasound: A Case Report and Review of Treatment Strategies.

BACKGROUND: Morel-Lavallée lesions, also known as an internal degloving injuries, occur hours to months after high-speed shearing trauma, usually in the peri-trochanteric region. These are uncommon injuries, and are often missed as part of the trauma examination. Failure to diagnose or treat these lesions may result in complications, such as infected seromas, chronic cosmetic deformities, capsule formation, or skin necrosis. There are no formalized societal guidelines for management, but smaller studies have recommended compression alone for asymptomatic lesions, aspiration for small symptomatic lesions, and open debridement for large lesions. CASE REPORT: A young woman presented with swelling, fluctuance, and paresthesia to her right hip after falling off her bicycle 1 week earlier. Physical examination showed a fluctuant and hypoesthetic area over the greater trochanter and point-of-care ultrasound showed a hypoechoic and compressible fluid collection between a fascial layer and a subcutaneous layer, confirming the diagnosis of a Morel-Lavallée lesion (internal degloving injury). Symptoms did not improve with compression alone, but did improve after fluid aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Morel-Lavallée lesions are frequently missed traumatic injuries. Morel-Lavallée lesions can be diagnosed quickly and cost-effectively in the emergency department through the combination of a thorough history, physical examination, and bedside ultrasound. Although there are no formal societal guidelines, limited studies suggest management strategies, including compression, aspiration, and open debridement, with treatments varying by symptom severity and lesion size.

Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities.

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.

Using Deep Learning to Detect the Presence and Location of Hemoperitoneum on the Focused Assessment with Sonography in Trauma (FAST) Examination in Adults.

Abdominal ultrasonography has become an integral component of the evaluation of trauma patients. Internal hemorrhage can be rapidly diagnosed by finding free fluid with point-of-care ultrasound (POCUS) and expedite decisions to perform lifesaving interventions. However, the widespread clinical application of ultrasound is limited by the expertise required for image interpretation. This study aimed to develop a deep learning algorithm to identify the presence and location of hemoperitoneum on POCUS to assist novice clinicians in accurate interpretation of the Focused Assessment with Sonography in Trauma (FAST) exam. We analyzed right upper quadrant (RUQ) FAST exams obtained from 94 adult patients (44 confirmed hemoperitoneum) using the YoloV3 object detection algorithm. Exams were partitioned via fivefold stratified sampling for training, validation, and hold-out testing. We assessed each exam image-by-image using YoloV3 and determined hemoperitoneum presence for the exam using the detection with highest confidence score. We determined the detection threshold as the score that maximizes the geometric mean of sensitivity and specificity over the validation set. The algorithm had 95% sensitivity, 94% specificity, 95% accuracy, and 97% AUC over the test set, significantly outperforming three recent methods. The algorithm also exhibited strength in localization, while the detected box sizes varied with a 56% IOU averaged over positive cases. Image processing demonstrated only 57-ms latency, which is adequate for real-time use at the bedside. These results suggest that a deep learning algorithm can rapidly and accurately identify the presence and location of free fluid in the RUQ of the FAST exam in adult patients with hemoperitoneum.

Point-of-Care Ultrasound For Differentiating Ileocolic From Small Bowel-Small Bowel Intussusception.

BACKGROUND: Intussusception is a common pediatric emergency. The two types of intussusception are ileocolic intussusception (ICI) and small bowel-small bowel intussusception (SB-SBI), and neither are easily distinguished clinically. ICI requires radiology personnel and potentially surgical assistance for its reduction. SB-SBI is managed expectantly, as many resolve spontaneously. Differentiating between ICI and SB-SBI through point-of-care ultrasound (POCUS) requires an understanding of their salient features. Identification of the correct type of intussusception immediately assists decision making and patient disposition. OBJECTIVE OF THE REVIEW: Our objective was to provide guidance on POCUS technique for intussusception identification, and to review the ultrasound literature differentiating ICI from SB-SBI. METHODS: We systematically searched 3 separate databases and gray literature to identify articles that met our criteria and assessed them for final review. The final articles were graded for quality using The National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. RESULTS: A total of 858 articles were identified. Six articles were included in the final review. All studies were conducted in pediatric patients in different countries. Most were found to have a fair quality of evidence. The linear transducer is used when evaluating intussusception. Both ICI and SB-SBI are identified easily on POCUS, but they differ sonographically with respect to region within the abdomen, intussusception parameters, lymph nodes, and other salient features seen on real-time video. CONCLUSIONS: ICI and SB-SBI can be identified and differentiated using several sonographic features. POCUS is capable of expeditiously aiding the emergency physician's decision making and disposition when managing intussusception.

Association of thoracic cage fractures and pericardial effusion in blunt trauma.

BACKGROUND: Several case reports suggest that penetrating thoracic cage fractures are an important cause for hemopericardium and cardiac tamponade following blunt trauma. However, the prevalence of this mechanism of injury is not fully known, and considering this association may provide a better understanding of the utility of cardiac component of the FAST (Focused Assessment with Sonography for Trauma). OBJECTIVE: To determine the association of thoracic cage fractures and pericardial effusion in patients with blunt trauma. METHODS: We performed a retrospective, multicenter cohort study using the Trauma Quality Improvement Program (TQIP) database (2015-2017) of adults ≥18 years of age whose mechanism of injury was either a fall or motor vehicle accident. Thoracic cage fractures were defined as any rib or sternum fracture. The primary outcome was the presence of pericardial effusion. Confounding variables were accounted for using multivariable logistic regression. RESULTS: We included 1,673,704 patients in the study; 226,896 (14%) patients had at least one thoracic cage fracture. A pericardial effusion was present in 4923 (0.3%) patients. When a thoracic cage fracture was present, the odds of having a pericardial effusion was significantly higher (adjusted Odds Ratio [aOR] 6.5 [95% CI: 6.1-7.0]). Patients with left and right-sided rib fractures had similar odds of a pericardial effusion (aOR 1.2 [95% CI 1.04-1.4]). Sternal fractures carried the highest odds of having a pericardial effusion (aOR 11.1 [9.9-12.3]). CONCLUSION: Thoracic cage fractures secondary to blunt trauma represent a significant independent risk factor for the development of a pericardial effusion. Our findings lend support for the mechanism of bony injuries causing penetrating cardiac trauma. Given these findings, and the fact that many thoracic cage fractures are detected after the initial evaluation, we support maintaining the cardiac view in the FAST examination for all blunt trauma patients.

Hemopericardium and Cardiac Tamponade After Blunt Thoracic Trauma: A Case Series and the Essential Role of Cardiac Ultrasound.

BACKGROUND: Severe cardiac injury caused by penetrating rib or sternal fractures after blunt chest trauma is a rare clinical entity that has been described in only a few case reports over the last half-century. As a result, questions have arisen about the utility of the cardiac component in the Focused Assessment with Sonography in Trauma (cFAST) examination in evaluating blunt trauma patients. CASE REPORT: We present a series of 3 patients who sustained blunt trauma and were discovered on cFAST examination to have developed pericardial tamponade from overlying rib or sternal fractures in the emergency departments of two academic level I trauma hospitals in the United States. Why Should an Emergency Physician Be Aware of This? These cases highlight the need for emergency and trauma physicians to be aware of blunt-induced, penetrating trauma to the heart and mediastinum, and for future trauma care guidelines to consider the importance of the cFAST examination.

The Diagnostic Accuracy of Ultrasonography for the Diagnosis of Rib Fractures in Patients Presenting to Emergency Department With Blunt Chest Trauma.

BACKGROUND: Rib fractures are the most common complications of blunt chest trauma (BCT). Computed tomography (CT) is the modality of choice for BCT, but with several disadvantages. Ultrasonography (US) is an inexpensive, readily available, and relatively harmless imaging alternative. However, a direct comparison of the sonographic evaluation of the rib as a whole with CT as a reference has not been performed to date. OBJECTIVE: This study aimed to compare the diagnostic accuracy of US with CT for the detection of rib fractures in patients who presented to emergency department (ED) with BCT. METHODS: We included a convenience sample of adult patients who presented to the ED with thoracic pain after BCT in the last 24 h in this prospective, observational, diagnostic accuracy study. The diagnostic utility of US performed by an emergency physician was compared with thorax CT. RESULTS: The final study population included 145 patients. The diagnostic accuracy of US was 80% with a sensitivity of 91.2% and specificity of 72.7% for the detection of any rib fracture (positive likelihood ratio 3.4 and negative likelihood ratio 0.12). If we considered each rib separately, the sensitivity of US decreased to 76.7% and specificity increased to 82.7% (81.3% accuracy). CONCLUSIONS: A negative US of the site of the highest tenderness and neighboring ribs in a patient with BCT who presented to the ED with lateralizing pain decreases the possibility of a rib fracture significantly. However, a positive US performs poorly to specify the exact location and number of the fractured ribs.

Transperineal Ultrasound in the Diagnosis of Proctitis in the Emergency Department.

BACKGROUND: Patients with anorectal complaints commonly present to the emergency department (ED). In patients with prior history of pelvic radiation and those with risk factors for sexually transmitted infections, proctitis is frequently on the differential diagnosis. Computed tomography (CT) scans are frequently done in patients with atypical presentations and those with broader differential diagnoses. Although in cases with suspected uncomplicated proctitis, conducting a point-of-care transperineal ultrasound (TPUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management, thus limiting the need for CT scan, a frequent flow-limiting step in the ED. CASE REPORT: In this article, we present a brief case series of patients presenting to the ED with anorectal complaints in whom TPUS revealed circumferential symmetric rectal wall edema and pericolonic stranding suggestive of proctitis. History and subsequent imaging further supported these diagnoses; we also briefly detail the patients' clinical course and outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We propose the use of TPUS as the screening imaging for anorectal pathologies and those with suspected proctitis to increase its use among emergency physicians. We review the main sonographic features of proctitis alongside reports from clinical cases, as well as the potential advantages of TPUS as a first-line imaging modality as compared with CT or magnetic resonance imaging. Although the complexities of anorectal anatomy can make TPUS a more difficult ultrasound modality to master, integrating TPUS into clinical practice will prove beneficial to both physician and patient.

A Case of Covid-19 Diagnosed at Home With Portable Ultrasound and Confirmed With Home Serology Test.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has pushed us to find better ways to accurately diagnose what can be an elusory disease, preferably in a way that limits exposure to others. The potential for home diagnosis and monitoring could reduce infectious risk for other patients and health care providers, limit use of finite hospital resources, and enable better social distancing and isolation practices. CASE REPORT: We report a case of an otherwise healthy emergency physician diagnosed with COVID-19 at home using portable ultrasound, pulse oximetry, and antibody testing. Her clinical picture and typical lung findings of COVID-19 on ultrasound, combined with a normal echocardiogram and negative deep vein thrombosis study, helped inform her diagnosis. She then monitored her clinical course using pulse oximetry, was able to self-isolate for 4 weeks, and had an uneventful recovery. Her diagnosis was confirmed with a positive IgG antibody test after 3 weeks. CONCLUSIONS: Novel times call for novel solutions and our case demonstrates one possible path for home diagnosis and monitoring of COVID-19. The tools used, namely ultrasound and pulse oximetry, should be familiar to most emergency physicians. Ultrasound in particular was helpful in eliminating other potential diagnoses, such as pulmonary embolus.

Are All Deep Learning Architectures Alike for Point-of-Care Ultrasound?: Evidence From a Cardiac Image Classification Model Suggests Otherwise.

OBJECTIVES: Little is known about optimal deep learning (DL) approaches for point-of-care ultrasound (POCUS) applications. We compared 6 popular DL architectures for POCUS cardiac image classification to determine whether an optimal DL architecture exists for future DL algorithm development in POCUS. METHODS: We trained 6 convolutional neural networks (CNNs) with a range of complexities and ages (AlexNet, VGG-16, VGG-19, ResNet50, DenseNet201, and Inception-v4). Each CNN was trained by using images of 5 typical POCUS cardiac views. Images were extracted from 225 publicly available deidentified POCUS cardiac videos. A total of 750,018 individual images were extracted, with 90% used for model training and 10% for cross-validation. The training time and accuracy achieved were tracked. A real-world test of the algorithms was performed on a set of 125 completely new cardiac images. Descriptive statistics, Pearson R values, and κ values were calculated for each CNN. RESULTS: Accuracy ranged from 96% to 85.6% correct for the 6 CNNs. VGG-16, one of the oldest and simplest CNNs, performed best at 96% correct with 232 minutes to train (R = 0.97; κ = 0.95; P < .00001). The worst-performing CNN was the newer DenseNet201, with 85.6% accuracy and 429 minutes to train (R = 0.92; κ = 0.82; P < .00001). CONCLUSIONS: Six common image classification DL algorithms showed considerable variability in their accuracy and training time when trained and tested on identical data, suggesting that not all will perform optimally for POCUS DL applications. Contrary to well-established accuracies for CNNs, more modern and deeper algorithms yielded poorer results.

Point-of-Care Ultrasound in the Evaluation of COVID-19.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care. OBJECTIVES: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic. DISCUSSION: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings. CONCLUSION: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.

Ultrasound-Guided Manual Testicular Detorsion in the Emergency Department.

BACKGROUND: Scrotal ultrasound helps in the rapid diagnosis of complete testicular torsion and assessment of alternative causes of acute scrotal pain. Early detection of torsion of the testis and reperfusion, either manually or surgically, is paramount to preserving testicular viability. Manual detorsion also offers immediate symptom relief by alleviating ischemia. Bedside ultrasound performed by a trained emergency physician (EP) can significantly reduce the time to diagnosis and reperfusion by means of performing an ultrasound-guided manual detorsion in the emergency department (ED). CASE REPORT: We report two cases of ultrasound-guided manual detorsion of testis that were performed successfully by EPs in the ED. After manual detorsion, both patients underwent nonemergent orchidopexy and recovered well after surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Manual testicular detorsion is a simple, safe, and effective maneuver that can be performed in the ED by EPs. Bedside ultrasound is helpful in confirming the diagnosis of complete torsion of the testicle (no blood flow) and successful reperfusion after manual detorsion. We recommend EPs be trained to perform scrotal ultrasound and manual detorsion of a torted testicle. We strongly emphasize that manual detorsion of the testes is not a substitute for definitive surgical management and should only be used as a temporary measure for reperfusion to allow more time to organize the logistics of surgery, which can be critical in remote settings.

Identifying infant hydrocephalus in the emergency department with transfontanellar POCUS.

Hydrocephalus carries significant morbidity in the infant population. Although clinical symptoms are often nonspecific, hydrocephalus is easily identified using transfontanellar sonography. In this review, we provide the emergency physician with a succinct overview of infant hydrocephalus and the point-of-care ultrasound (POCUS) technique for identification of this pathology.

Bedside Use of Speckle Tracking Echocardiography in the Emergency Department to Identify Acute Myocardial Infarction.

BACKGROUND: Rapid diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) is often hindered by the limitations of the electrocardiogram (ECG). Speckle tracking echocardiography (STEch) is a semiautomated, computer-assisted process that provides accurate detection of regional ventricular wall motion abnormalities and can be performed at the bedside by operators with limited experience. CASE REPORTS: Two separate patients, each with history and ECG findings concerning for AMI, were evaluated using STEch performed by an emergency physician. Ventricular wall motion abnormalities found on STEch accurately reflected the findings of emergent cardiac catheterization, with one patient requiring urgent coronary artery revascularization and the other with no coronary artery occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: STEch is a novel, easy-to-use form of echocardiography that can be used in the ED to identify patients with AMI who would benefit from emergent revascularization.

Hemorrhagic Cholecystitis: A Case of Expedited Diagnosis by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Hemorrhagic cholecystitis is a rare complication of acute cholecystitis and is a potentially fatal diagnosis. It may be difficult to detect because the symptoms are similar to more common diagnoses. Point-of-care ultrasound is a useful imaging technique in the emergency setting and is readily available to allow for immediate interpretation and application of the results to guide medical decision making. CASE REPORT: We report a 76-year-old man with a history of hypertension, hyperlipidemia, diabetes, atrial fibrillation on warfarin, and coronary artery disease presenting with epigastric pain radiating to the back, nausea, and vomiting who was found to have hemorrhagic cholecystitis with gallbladder perforation. Ultrasound of the abdominal right upper quadrant showed a large, hyperechoic, nonshadowing, globular structure visualized within the lumen of the gallbladder extending from the neck through the body. The gallbladder wall was noted to be 0.72 cm with wall edema, focal pericholecystic fluid, and a positive sonographic Murphy sign suggestive of acute cholecystitis. The abnormal appearance of the gallbladder contents was suspected to be blood. Computed tomography angiography was performed and confirmed the diagnosis of acute hemorrhagic cholecystitis with perforation. Blood was noted to track from the cystic duct to the gallbladder lumen. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is a unique case of hemorrhagic cholecystitis visualized on bedside ultrasound. This case shows that the use of point-of-care ultrasound by emergency medicine providers can facilitate the rapid recognition and treatment of specific, life-threatening hepatobiliary pathology while excluding alternate diagnoses.

PoCUS evaluating blunt thoracic trauma: a retrospective analysis of 18 months of emergency department activity.

Blunt thoracic injury (BTI) constitutes a common presentation in emergency department: rib fractures are the most common injuries. Chest X-ray (CXR) has a limited sensitivity to identify rib fractures. We perform this retrospective study in our emergency department collecting all patients with BTI during an 18-month period. PoCUS was performed prior to acquire CXR or CT. We evaluated 1672 patients with BTI, and we reported rib fractures in 689 patients (41.21%). PoCUS was performed in 190 patients. PoCUS in emergency medicine has an increasing role, especially in BTI, but less clear is its role in detecting ribs fracture. PoCUS seems to be an effective method for diagnosing rib fracture in patients with blunt chest trauma if collaborative and with a well-isolated trauma. We used the trick of patients' self-positioning probe in the most painful site, and this could reduce the time and the pain of the examination.