Bedside Ultrasonography Research Articles

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol.

Fluid retention is the most common risk factor for mortality and cardiovascular complications in patients with volume-overloaded disease states. The extent of diuresis or fluid removal is frequently determined by physical examination which is subject to inaccuracies. Bedside ultrasound (US) is a portable tool that brings real-time diagnostic imaging to the patient's bedside. This versatile modality makes it possible for the clinician to investigate patients' extravascular and intravascular volume states. The extravascular volume, particularly in the case of pulmonary edema, can be quantitatively assessed by US of the anterior chest. Intravascular volume is estimated by visualizing the inferior vena cava (IVC) caliber. Taken together, the degree of extravascular lung water and the IVC caliber provide objective data that can guide the clinician to determine the level of diuresis needed to effectively yet safely treat pulmonary edema. The objective of this article is threefold: 1) to summarize the findings of previous studies on the efficacy of portable US to guide fluid management, 2) to describe a proposed ultrasound protocol to help guide fluid management, and 3) to elucidate techniques that address the measurement of intravascular and extravascular volumes using portable US.

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol

Bedside Ultrasound Assessment of Jugular Venous Compliance as a Potential Point-of-Care Method to Predict Acute Decompensated Heart Failure 30-Day Readmission.

BackgroundHeart failure is one of the most costly diagnosis‐related groups, largely because of hospital readmissions. Objective assessment of volume status to ensure optimization before hospital discharge could significantly reduce readmissions. We previously demonstrated an ultrasound method of quantifying percentage of cross‐sectional area (CSA) change of the right internal jugular vein with Valsalva that reliably estimates central venous pressure.Methods and ResultsPatients admitted with acute decompensated heart failure (ADHF) underwent ultrasound measurements of the right internal jugular vein at end‐expiration and during the strain phase of Valsalva to determine a percentage of CSA change. An initial subgroup of patients with right heart catheterization and accompanying ultrasound measurements of the right internal jugular vein identified a percentage of CSA change predictive of right atrial pressure (RAP) ≥12 mm Hg. Images of admitted ADHF patients were obtained at admission and discharge for final analysis. Simultaneous right heart catheterization and right internal jugular vein ultrasound measurements demonstrated that a <66% CSA change predicted RAP ≥12 mm Hg (positive predictive value: 87%; P<0.05, receiver operating characteristic curve). Elevated admission RAP by percentage of CSA change normalized by discharge (P<0.05), indicating that this test is significantly responsive to therapeutic interventions. Using the cutoff value of 66% CSA change, normal RAP at discharge had 91% predictive value for patients avoiding 30‐day readmission (P<0.05).ConclusionsThis bedside ultrasound technique strongly correlates to invasive RAP measurement in ADHF patients, identifies restoration of euvolemia, and is predictive of 30‐day ADHF readmission. This tool could help guide inpatient ADHF treatment and may lead to reduced readmissions.

Cardiac tamponade by peripherally inserted central catheter in preterm infants: role of bedside ultrasonography and therapeutic approach.

to determine the incidence of pericardial effusion with cardiac tamponade in preterm infants in a pediatric intensive care unit, with emphasis on the relationship between pericardial effusion and peripherally inserted central catheter, and to evaluate the role of bedside ultrasound in approaching these cases. we conducted a retrospective analysis of patients admitted to a pediatric intensive care unit between July 2014 and December 2016, who presented pericardial effusion with hemodynamic repercussion, evaluated by ultrasonography. we studied 426 patients admitted to the five beds of the neonatal unit. In the period, there were 285 bedside ultrasound exams. We found six cases of pericardial effusion, four of which with obstructive shock and need for pericardial drainage. There was no procedure-related mortality, and all patients evolved with hemodynamic improvement after the procedure. The incidence of pericardial effusion was 2.4 cases per year. the incidence of pericardial effusion is low in neonates, but early diagnosis is fundamental due to high morbidity and mortality, especially in cases of abrupt onset. All cases were diagnosed by bedside ultrasonography, demonstrating its importance in the screening of these cases, especially in shocks of uncertain etiology and neonates with sudden onset hemodynamic instability who are using central venous access.

Bedside sonography assessment of extravascular lung water increase after major pulmonary resection in non-small cell lung cancer patients.

Extra vascular lung water (EVLW) following pulmonary resection increases due to fluid infusion and rises in capillary surface and permeability of the alveolar capillary membranes. EVLW increase clinically correlates to pulmonary oedema and it may generate impairments of gas exchanges and acute lung injury. An early and reliable assessment of postoperative EVLW, especially following major pulmonary resection, is useful in terms of reducing the risk of postoperative complications. The currently used methods, though satisfying these criteria, tend to be invasive and cumbersome and these factors might limit its use. The presence and burden of EVLW has been reported to correlate with sonographic B-line artefacts (BLA) assessed by lung ultrasound (LUS). This observational study investigated if bedside LUS could detect EVLW increases after major pulmonary resection. Due to the clinical association between EVLW increase and impairment of gas exchange, secondary aims of the study included investigating for associations between any observed EVLW increases and both respiratory ratio (PaO2/FiO2) and fluid retention, measured by brain natriuretic peptide (BNP). Overall, 74 major pulmonary resection patients underwent bedside LUS before surgery and at postoperative days 1 and 4, in the inviolate hemithorax which were divided into four quadrants. BLA were counted with a four-level method. The respiratory ratio PaO2/FiO2 and fluid retention were both assessed. BLA resulted being increased at postoperative day 1 (OR 9.25; 95% CI, 5.28-16.20; P<0.0001 vs. baseline), and decreased at day 4 (OR 0.50; 95% CI, 0.31-0.80; P=0.004 vs. day 1). Moreover, the BLA increase was associated with both increased BNP (OR 1.005; 95% CI, 1.003-1.008; P<0.0001) and body weight (OR 1.040; 95% CI, 1.008-1.073; P=0.015). Significant inverse correlations were observed between the BLA values and the PaO2/FiO2 respiratory ratios. Our results suggest that LUS, due to its non-invasiveness, affordability and capacity to detect increases in EVLW, might be useful in better managing postoperative patients.

Surgeon-Performed Ultrasound in Diagnosing Acute Cholecystitis and Appendicitis

BackgroundThe use of ultrasound (US) outside the radiology department has increased the last decades, but large studies assessing the quality of bedside US are still lacking. This study evaluates surgeon-performed US (SPUS) and radiologist-performed US (RPUS) with respect to biliary disease and appendicitis.MethodsBetween October 2011 and November 2012, 300 adult patients, with a referral for an abdominal US, were prospectively enrolled in the study and examined by a radiologist as well as a surgeon. The surgeons had undergone a 4-week-long US education. US findings of the surgeon and of the radiologist were compared to final diagnosis, set by an independent external observer going through each patient’s chart.ResultsAmong 183 patients with suspected biliary disease, 74 had gallstones and 21 had acute cholecystitis. SPUS and RPUS diagnosed gallstones with a sensitivity of 87.1 versus 97.3%. Specificity was 96.0 versus 98.9%, and the accuracy 92.3 versus 98.2%. The sensitivity, specificity and accuracy for acute cholecystitis by SPUS and RPUS were: 60.0 versus 80.0%, 98.6 versus 97.8% and 93.9 versus 95.6%, respectively. Among 58 patients with suspected appendicitis, 15 had the disease. The sensitivity, specificity and accuracy for appendicitis by SPUS and RPUS were: 53.3 versus 73.3%, 89.7 versus 93.3% and 77.3 versus 86.7%, respectively.ConclusionSPUS is reliable in diagnosing gallstones. Diagnosing cholecystitis and appendicitis with US is more challenging for both surgeons and radiologists.Trial registration numberThe study was registered at clinicaltrials.gov. Registration number: NCT02469935.

Abstract PD-005: ASSESSMENT OF ENDOTRACHEAL TUBE TIP POSITION BY BEDSIDE ULTRASOUND IN A PEDIATRIC INTENSIVE CARE UNIT – A DESCRIPTIVE STUDY

Abstract PD-005: ASSESSMENT OF ENDOTRACHEAL TUBE TIP POSITION BY BEDSIDE ULTRASOUND IN A PEDIATRIC INTENSIVE CARE UNIT – A DESCRIPTIVE STUDY

Comparative Study between Clinical and Ultrasound Diagnosis of Emergency of Gynecology

AbstractBackground: Acute pelvic pain accounts for up to 40% of the visits to gynecological emergency departments and may indicate a serious condition. Potentially life-threatening gynecological emergencies are acute pelvic conditions that may spontaneously evolve into a life threatening situation. They may also carry a risk of sequelae (organ failure or organ removal) or death in the absence of prompt diagnosis and treatment.The most common gynecological emergencies are ruptured ectopic pregnancy, adnexal torsion, and complicated pelvic inflammatory disease (tubo-ovarian abscess (TOA) and pyos-alpinx). Missing these high-risk conditions may delay treatment that could lead to potentially negative patient outcomes.Methods: This study was carried out over 1 year from September 2016 to September 2017 on 30 female patients. The records of all patients were review and data were collected prospectively. Our study included patients presented to the Emergency Department with gynecological emergencies.These gynecological emergencies included patients pre-sented with acute pelvic pain (e.g. ectopic pregnancy, torsion ovarian cyst, rupture ovarian cyst, pelvic inflammatory disease, tubo-ovarian abscess (TOA), and acute salpingitis) and/or vaginal bleeding (e.g. rupture uterus, and uterine tumors).Results: Ectopic pregnancy was the most common gyne-cological emergency seen in our study (about 46.67% of patients). Other diagnosis found in this study were adnexal torsion (about 16.67%), ovarian cyst rupture (about 13.33%), PID (about 13.33%), and uterine mass (about 10%).In this study, only about 53.33% of patients were diagnosed clinically before ultrasound was done. About 93.33% of patients were diagnosed after assessment by ultrasonography. There was statistically significant difference between clinical diagnosis and diagnosis after ultrasonography. (p<0.05).According to this study, there was a significant difference between clinical and radiological diagnosis using ultrasonog-raphy in diagnosis of ectopic pregnancy, adnexal torsion, and ovarian cyst rupture. (p<0.05).According to our data, physical examination cannot be used alone to safely rule out a surgical emergency in a woman presenting with acute pelvic pain. This suggests the benefit of adding bedside ultrasonography in the first-line diagnostic management of suspected gynecological emergencies.Conclusion: Adding Ultrasonography as a bedside test was found to be superior to physical examination in diagnosis of acute pelvic pain. If a gynecologic disorder couldn't be confirmed, or the sonographic finding are equivocal, Multi-Detector Computed Tomography (MDCT) is another imaging choice.Ultrasound is generally accepted as the first imaging modality used in patients with acute pelvic pain. The true value of ultrasound in acute pelvic pain lies in its ability to detect gynecologic disorders.

Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound

BackgroundSeptic pulmonary embolism (SPE) is a rare disorder caused by metastasis of infectious thrombi to the lungs. Most commonly, this occurs as a result of infectious endocarditis. This clinical entity may easily be confused for more common and less mortal diagnoses such as pneumonia, bronchitis, or pulmonary embolism. Case ReportA 47-year-old woman presented in respiratory distress with a complaint of cough productive of rusty sputum, shortness of breath, and pleuritic chest pain. A bedside ultrasound suggested endocarditis and SPE. She was resuscitated and admitted to the hospital for surgical source control and continued i.v. antibiotics. Why Should an Emergency Physician Be Aware of This?SPE is a rare disorder that may be easily missed but carries a high mortality rate. Additionally, the presence of the embolic phenomena makes the diagnosis of infectious endocarditis more attainable in the emergency department (ED). To our knowledge, this case is the first in which ED bedside ultrasound was used to make the diagnosis of SPE due to infectious endocarditis.

Bedside Sonography Performed by Emergency Physicians to Detect Appendicitis in Children.

The aim of this study was to evaluate the ability of emergency physicians with various levels of point-of-care ultrasound (POCUS) experience to detect appendicitis with POCUS among children visiting a pediatric emergency department (ED). A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy or hemodynamic instability requiring resuscitation or were transferred with proven diagnosis of appendicitis. Participating physicians had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography while the others had basic experience in abdominal POCUS. All the participating physicians received a 1-hour didactic and practical training session on appendix ultrasound. The treating physician performed POCUS following initial physical examination, before further radiologic evaluation. POCUS examinations were recorded as positive for appendicitis, normal, or inconclusive, with normal or inconclusive studies considered negative. Final outcomes were determined by pathology and/or operative reports for surgical cases and telephone follow-up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95% confidence interval (CI) ranging from 66% to 90%. Of the 140 approached patients, 121 accepted to participate and were recruited. After four patients were excluded for missing POCUS data, 117 patients were included in the primary analysis, of whom 51 (44%) had appendicitis. Twenty-two physicians performed between one and 20 POCUS procedures. The POCUS was positive in 39, negative in nine, and inconclusive in 69 patients. POCUS was interpreted as positive in 27 of 51 appendicitis for a sensitivity of 0.53 (95% CI= 0.40-0.66). A negative or inconclusive POCUS was reported for 54 of 66 patients without appendicitis (specificity= 0.82; 95% CI= 0.71-0.89). This study shows limited sensitivity and specificity of POCUS for appendicitis in children, with a high proportion of inconclusive examinations, when performed by emergency physicians with various level of experience in POCUS.

An Exploratory Study of Sectra Table Visualization Improves the Effectiveness of Emergency Bedside Echocardiography Training.

Echocardiography is an essential tool in emergency medicine, and its training is the most challenging of all types of bedside ultrasound (US) training. This study investigated the effectiveness of the Sectra Table (Sectra AB, Linköping, Sweden), an anatomy visualization and collaboration tool, in improving the quality of echocardiography training for emergency medicine physicians. We conducted an exploratory prospective observational study from 2015 to 2017 and enrolled 66 trainees who participated in a 2.5-day bedside US course organized by the emergency department (ED) of Peking Union Medical College Hospital. The study participants underwent 2 different training programs: the first group received standard training, and the second group was trained with Sectra Table experiences integrated into the echocardiography training curriculum. After the training sessions, both groups were evaluated for their hands-on echocardiography performance. The new training program with the Sectra Table significantly increased trainees' self-confidence in performing bedside echocardiography. The Sectra Table trainees had a higher performance rating than the trainees in the traditional program, with a mean total assessment score of 40.5 versus 26.5 for traditional training (P < .01). The improved performance was evident for all subcategories of echocardiography. The higher performance rating of the Sectra Table trainees was also statistically significant after adjusting for confounders, including prior training experiences, baseline confidence in independently performing ED US examinations, the number of ED US examinations performed, years in ED practice, and physician seniority. Our analysis suggests that integrating the Sectra Table into echocardiography training may improve the effectiveness of training programs.

Evaluation of the role of bedside ultrasonography in the detection of traumatic occult pneumothorax

BackgroundPrimary management of pneumothorax is usually as simple as it can be done by junior physician. But diagnosis of pneumothorax is sometimes as difficult as it can be missed by senior physician and lead to serious complications that may endanger the patient's life. MethodsThis study was conducted on 80 polytraumatized adult patients, within the same day of trauma. They presented to the Emergency Department, Tanta University, Egypt with chest trauma in the period between October 2016 to the end of January 2018. All patients were subjected to chest X-ray either erect position when possible or supine position revealing no pneumothorax. Subsequently, all of those patients underwent thoracic ultrasonography prior to whole body CT scanning performed within 2 h of admission. ResultsUltrasonography detected pneumothorax in 56 out of 62 patients having occult pneumothorax with sensitivity up to 90.32% and positive predictive value of 96.55%. On the other hand, ultrasonography succeeded in exclusion of occult pneumothorax in 16 out of 18 patients that were free of occult pneumothorax in their CT with specificity reaching 88.89% and negative predictive value of 72.73%, the overall accuracy was calculated to be 90%. ConclusionsBedside thoracic ultrasonography is a simple, rapid and reliable tool with high sensitivity, specificity and accuracy that can be depend on for diagnosis of occult pneumothorax in chest trauma patients.

LO82: Normal bedside ultrasound of growth plates in healthy children

Introduction: The diagnosis of Salter-Harris Type 1 fractures in the Emergency Department (ED) is primarily clinical, as radiographs are usually unrevealing. We hypothesize that bilateral asymmetry of the growth plate, detected using bedside ultrasound (US), could improve the accuracy of this diagnosis in the ED. This study seeks to determine growth plate size according to age, and to establish normal variation in bilateral symmetry of growth plate cartilage, for the ulna, radius, tibia, and fibula, using bedside US in normal healthy children. Methods: This prospective observational study was conducted in a convenience sample of children ages 0-17 during planned visits to an elementary school, high school, and an outpatient pediatric clinic. A sample size of 177 was determined with a linear regression model using previously published data on the subject. The study was approved by the hospital and universitys ethics board. After a medical questionnaire with a research nurse, the participants underwent ultrasound evaluation of bilateral ulnae, radii, fibulae, and tibiae, to obtain still images of the physes from two orthogonal views. The evaluations were performed by 3 medical residents, 1 medical student, and by the supervising emergency physician. All ultrasonographers were EDE1 certified and specifically trained for growth plate imagery. The still images were evaluated ulteriorly and measurements taken of the physeal cartilage. Ten percent of the patients had their images re-evaluated by the supervising physician to determine inter-rater reliability. Results: A total of 227 patients were recruited. The median age was 8 years old with an interquartile range of (3;14). Mean growth plate size by age was determined, confirming decreasing growth plate size with advancing age for all articulations. The percentage of absolute difference between right and left, for all growth plates together, was a mean of 17% with a 95% CI of 16-19%. The overall inter-rater reliability was excellent at 0.84. Conclusion: This study establishes a reproducible technique of measuring growth plates with ultrasound. We suspect that increased asymmetry at the growth plate, beyond this established normal variation, may signify a physis widening or hematoma consistent with a Salter-Harris Type 1 fracture; this will be evaluated in a second study.

Evaluating and assessing the prevalence of bedside ultrasound in emergency departments in China.

To survey the prevalence of bedside ultrasound assessment in emergency departments (EDs) in China. We designed an online survey for emergency physicians based in the China. The questionnaire included sixteen items querying common ED bedside ultrasound practices. Respondents were recruited via weblinks sent through social media and a popular Chinese emergency medicine website. Survey data was collected from April through June, 2016. Four hundred and twenty-eight physicians responded to this survey; more than 80% of respondents reported working clinically in the ED. Ninety-eight percent of respondents agreed on the clinical importance and value of bedside ultrasound. However, less than half of participants' EDs had ultrasound devices, and less than half of the respondents said they knew how to perform bedside ultrasound. Less than 20% of respondents reported having had formal training in bedside ultrasound. There is a strong interest in bedside ultrasound in Chinese EDs. Emergency physicians participating in this study considered bedside ultrasound a necessary skill, but, because there is a lack of training, most emergency physicians reported they did not know how to perform bedside ultrasonography. There is likely an acute desire and need for bedside ultrasound training for Chinese emergency physicians.

Accuracy of Bedside Ultrasound for the Diagnosis of Skull Fractures in Children Aged 0 to 4 Years.

The aim of this study was to investigate the accuracy of bedside ultrasound (US) performed by emergency physicians for diagnosing skull fractures in children 0 to 4 years old compared with the accuracy of head computed tomography (CT). We also sought to investigate characteristics and precautions associated with US. This single-center prospective study involved children 0 to 4 years old who had a history of head trauma. Bedside US was performed by emergency medicine physicians, and the results were compared with CT scan interpretations provided by attending radiologists. The accuracy of US for the diagnosis of skull fractures was calculated, and the errors were reviewed. A total of 87 patients were enrolled. Skull fracture was present in 13 patients (14.9%), according to CT. Bedside US had a sensitivity and specificity of 76.9% (95% confidence interval [CI], 46.0%-93.8%) and 100% (95% CI, 93.9%-100%), respectively. Overall positive predictive value was 100% (95% CI, 65.5%-100%), and negative predictive value was 96.1% (95% CI, 88.3%-99.0%). Three false-negative cases were observed. Bedside US performed by emergency medicine physicians with short focused US training is a useful tool for diagnosing skull fractures in children 0 to 4 years of age. However, there were 3 false-negative cases. A meticulous examination is needed in the area adjacent to the orbital wall and skull base.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound

BackgroundGonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis. Case ReportA 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 103/μL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. Why Should an Emergency Physician Be Aware of This?DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Bedside Ultrasound Diagnosis of Complete Achilles Tendon Tear in a 25-Year-Old Man with Calf Injury

Bedside Ultrasound Diagnosis of Complete Achilles Tendon Tear in a 25-Year-Old Man with Calf Injury

Noteworthy Professional News

Noteworthy Professional News

Evaluation of Snake Bites with Bedside Ultrasonography

Evaluation of Snake Bites with Bedside Ultrasonography

Bedside Ultrasonography as an Alternative to Computed Tomography Scan for the Measurement of Optic Nerve Sheath Diameter.

Background:Optic nerve sheath diameter (ONSD) as measured by optic nerve sheath ultrasonography (ONSU) is used as a surrogate marker of intracranial pressure (ICP), especially in resource-limited settings. There is a growing interest in the use of ONSU in emergency and high-altitude setups. Notwithstanding multiple studies done on this subject, there is a paucity of data regarding standardization of techniques and comparison of ONSU with computed tomography (CT).Materials and Methods:Thirty-five patients with a diagnosis of high-altitude cerebral edema were enrolled in the study. ONSD was measured in all patients using ONSU, along visual and coronal axis, and CT scan. We repeated ONSU in these patients on days 3, 7, 10, and 15 (day of discharge). Correlation between visual and coronal axis as well as CT scan was analyzed.Results:The correlation of visual to coronal and coronal to visual was equally significant (both correlation coefficients being R2 = 0.983). Correlation of ONSD by visual axis to CT scan was better than coronal axis (correlation coefficient R2 = 0.986 vs. 0.96, respectively).Conclusion:In our study, we found a strong correlation between the visual and coronal axes. Thus, either of the two axes can be used for monitoring ICP. However, it has been found that measurements along the coronal axis are challenging, especially in the emergency setup. ONSD measured along visual axis correlated better with CT scan as compared to the coronal axis.