Cardiac Point-of-care Ultrasound Research Articles

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review.

Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.

Integration of Cardiac Point of Care Ultrasound (POCUS) in a Medical Physiology Course During the Preclinical Curriculum

Background: The early integration of hands-on point-of-care ultrasound (POCUS) during medical students' preclinical curriculum has expanded the utilization of this tool which can provide rapid and effective bedside diagnosis in clinical practice. Many medical schools that have incorporated POCUS into their curriculum allude to the limitations of a large class size, learning retention, and applying these skills to aid in diagnosing pathologic conditions. Indeed, it is interesting that there is currently no consensus as to what and how much hands-on ultrasound training should be included in the medical school curriculum. At Midwestern University (MWU), we introduced a 4-year inclusion of ultrasound training throughout the medical curriculum. The core Physiology courses taken in winter and spring quarter of first year medical school, incorporate several mandatory ultrasound workshops taken by osteopathic medical students and podiatry students together. This study hypothesizes that the incorporation of cardiac POCUS in small group physiology workshops increases student confidence in their ability to measure the parameters to effectively assess cardiac output. Moreover, we hypothesize that this hands-on teaching tool reinforces the concepts taught in the didactic lectures, applying the material in a clinically relevant manner. Data obtained during the 2023-2024 winter quarter will be presented at the APS meeting. Methods: This study aims to utilize a brief survey administered via REDCap, in a questionnaire format to first year osteopathic medical students and podiatric medical students after the cardiac physiology workshop administered during the first year of medical school. Survey questions will be generated using Likert 5-point scales, ratings of (strongly agree to strongly disagree, very comfortable to very uncomfortable, high level of competence to no level of competence, and very confident to very unconfident). Survey questions will seek to assess confidence level using POCUS, ease of quantifying assessments, and differences in perceptions between podiatry and osteopathic medical students. Associations between two question responses will be assessed using the Chi-square test for independent responses and McNemar test to compare responses that were paired. A p-value &lt;0.05 for both tests will indicate statistical significance. Furthermore, we aim to determine whether retention and application of the information taught during the cardiac POCUS workshop can be evaluated by student performance on POCUS-specific exam questions. IRB approval is currently pending. Results: We plan to share: (1) the survey questions, (2) data obtained using POCUS from the last academic years class cohort and the current class (specifically relating to their use of POCUS to calculate cardiac output) to highlight the variability in these assessments, (3) exam question analyses for the last 2-years (as assessment outcomes), (4) survey responses from the current class, (5) correlations of student perceived confidence and determined understanding. Conclusion: The introduction of POCUS utilization during the physiology courses in the first year of Osteopathic and Podiatry pre-clinical years reinforces key concepts covered in didactic lectures. We hypothesize that student perceptions of these workshops will be largely positive and improve student confidence in POCUS use. No funding. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Effectiveness of a Brief Point of Care Ultrasound Course at a National Nephrology Conference.

The rising demand for point of care ultrasound (POCUS) instruction during nephrology fellowship has been limited due to a shortage of trained faculty and courses designed specifically for nephrologists. A hands-on POCUS pre-course was organized during the April 2023 National Kidney Foundation (NKF) Spring Clinical Meeting to address this challenge. The course consisted of pre-recorded lectures and a 4-hour hands-on workshop guided by multidisciplinary POCUS experts. The anonymous post-course survey received responses from 25 out of 39 participants, yielding a 64.1% response rate. On a scale of 0-10, confidence levels for acquiring kidney images rose from 2.6 + 2.3 (mean + SD) pre-workshop to 7.8 + 1.5 post-workshop (p<0.001). Similarly, a remarkable improvement in confidence for acquiring lung and cardiac images was seen as scores increased from 1.8 + 2.4 to 7.7 + 1.5 (p<0.001) and from 1.5 + 2.2 to 7.2 + 1.3 (p<0.001), respectively. Additionally, respondents reported a substantial improvement in their confidence to interpret kidney, lung, and cardiac POCUS images, with scores increasing from 4.5 + 2.2 to 7.7 + 1.1 (p<0.001), 2.3 + 2.4 to 7.6 + 1.5 (p<0.001), and 2 + 2 to 7.3 + 1.5 (p<0.001), respectively. Barriers to implementing POCUS use at institutions included a perceived lack of trained faculty, limited protected time for faculty, and insufficient support from division leadership. The NKF POCUS pre-course successfully improved participants' confidence in acquiring and interpreting basic POCUS images.

Validation of machine learning models for estimation of left ventricular ejection fraction on point-of-care ultrasound: insights on features that impact performance

BackgroundMachine learning (ML) algorithms can accurately estimate left ventricular ejection fraction (LVEF) from echocardiography, but their performance on cardiac point-of-care ultrasound (POCUS) is not well understood.ObjectivesWe evaluate the performance of an ML model for estimation of LVEF on cardiac POCUS compared with Level III echocardiographers’ interpretation and formal echo reported LVEF.MethodsClinicians at a tertiary care heart failure clinic prospectively scanned 138 participants using hand-carried devices. Video data were analyzed offline by an ML model for LVEF. We compared the ML model's performance with Level III echocardiographers' interpretation and echo reported LVEF.ResultsThere were 138 participants scanned, yielding 1257 videos. The ML model generated LVEF predictions on 341 videos. We observed a good intraclass correlation (ICC) between the ML model's predictions and the reference standards (ICC = 0.77–0.84). When comparing LVEF estimates for randomized single POCUS videos, the ICC between the ML model and Level III echocardiographers' estimates was 0.772, and it was 0.778 for videos where quantitative LVEF was feasible. When the Level III echocardiographer reviewed all POCUS videos for a participant, the ICC improved to 0.794 and 0.843 when only accounting for studies that could be segmented. The ML model's LVEF estimates also correlated well with LVEF derived from formal echocardiogram reports (ICC = 0.798).ConclusionOur results suggest that clinician-driven cardiac POCUS produces ML model LVEF estimates that correlate well with expert interpretation and echo reported LVEF.

The effect of real-time EF automatic tool on cardiac ultrasound performance among medical students.

Point-of-care ultrasound (POCUS) is a sensitive, safe, and efficient tool used in many clinical settings and is an essential part of medical education in the United States. Numerous studies present improved diagnostic performances and positive clinical outcomes among POCUS users. However, others stress the degree to which the modality is user-dependent, rendering high-quality POCUS training necessary in medical education. In this study, the authors aimed to investigate the potential of an artificial intelligence (AI) based quality indicator tool as a teaching device for cardiac POCUS performance. The authors integrated the quality indicator tool into the pre-clinical cardiac ultrasound course for 4th-year medical students and analyzed their performances. The analysis included 60 students who were assigned to one of two groups as follows: the intervention group using the AI-based quality indicator tool and the control group. Quality indicator users utilized the tool during both the course and the final test. At the end of the course, the authors tested the standard echocardiographic views, and an experienced clinician blindly graded the recorded clips. Results were analyzed and compared between the groups. The results showed an advantage in quality indictor users' median overall scores (P = 0.002) with a relative risk of 2.3 (95% CI: 1.10, 4.93, P = 0.03) for obtaining correct cardiac views. In addition, quality indicator users also had a statistically significant advantage in the overall image quality in various cardiac views. The AI-based quality indicator improved cardiac ultrasound performances among medical students who were trained with it compared to the control group, even in cardiac views in which the indicator was inactive. Performance scores, as well as image quality, were better in the AI-based group. Such tools can potentially enhance ultrasound training, warranting the expansion of the application to more views and prompting further studies on long-term learning effects.

Simulation training can improve internal medicine residents’ knowledge and comfort with cardiac point-of-care ultrasound to diagnose acute cardiovascular conditions

Few studies have examined the value of dedicated simulation-based point-of-care ultrasound (POCUS) training in improving Internal Medicine residents’ knowledge and comfort with cardiac POCUS to diagnose acute decompensated systolic heart failure and large pericardial effusion. This mixed-methods research included all 48 first-year Internal Medicine Residents receiving POCUS training at an urban academic centre. Participants were queried about their self-appraised cardiac POCUS knowledge, objectively tested on their cardiac POCUS knowledge, and surveyed about their comfort with cardiac POCUS tasks before and immediately after their training session, as well as 3 months later. Participants’ self-appraised knowledge regarding cardiac POCUS increased significantly from pre- to immediately post-intervention (31%–83%, Simulation-based training can be beneficial for teaching Internal Medicine residents the fundamental skills of cardiac POCUS as well as how to utilize the modality to diagnose acute decompensated systolic heart failure and large pericardial effusion.

Accuracy of Pediatric Interventricular Septal Thickness Measurement Obtained Via Point-of-Care Ultrasound: A Prospective Study.

Hypertrophic cardiomyopathy is a genetic, life-threatening cardiovascular disease that often goes unidentified in pediatric patients. Patients are often asymptomatic and neither history or physical examination are reliable to detect the disease. The only reliable method to diagnose hypertrophic cardiomyopathy is with echocardiography to look at interventricular septal thickness. Emerging literature has shown that cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians is as effective and accurate compared with cardiac echocardiography performed by pediatric cardiologists. The objective of the study was to determine the diagnostic accuracy of POCUS performed by ultrasound-trained PEM physicians in measuring the interventricular septum end diastole (IVSd) thickness in the pediatric emergency department. We conducted a prospective, single-center, observational, diagnostic accuracy study to examine the diagnostic accuracy of POCUS in measuring IVSd thickness in pediatric patients who presented to the pediatric emergency department with symptoms that prompted a cardiac POCUS. Cardiac POCUS findings were interpreted by a PEM physician at the bedside and retrospectively by a pediatric cardiologist. Diagnostic concordance of the measurements obtained by the PEM physician and cardiologist was assessed. Forty-eight patients were enrolled. Median patient age was 13.4 years. There was excellent diagnostic agreement on the measurement of the IVSd thickness between PEM physicians and the pediatric cardiologist (81.25% of cases; 39/48). Disagreement was seen in 18.75% of the cases (9/48). The mean error of disagreement was -0.32, with a 95% confidence interval of -0.37 to -0.28. Overall, the mean error of both agreement and disagreement was -0.046, with 95% confidence interval of -0.08 to -0.01 and P value of 0.008. Point-of-care ultrasound performed by ultrasound-trained PEM physicians to measure pediatric IVSd thickness has a high diagnostic accuracy with excellent agreement with a pediatric cardiologist.

Change in economy of ultrasound probe motion among general medicine trainees

ObjectivesTo observe change in economy of 9 ultrasound probe movement metrics among internal medicine trainees during a 5-day training course in cardiac point of care ultrasound (POCUS).MethodsWe used a novel probe tracking device to record nine features of ultrasound probe movement, while trainees and experts optimized ultrasound clips on the same volunteer patients. These features included translational movements, gyroscopic movements (titling, rocking, and rotation), smoothness, total path length, and scanning time. We determined the adjusted difference between each trainee’s movements and the mean value of the experts’ movements for each patient. We then used a mixed effects model to trend average the adjusted differences between trainees and experts throughout the 5 days of the course.ResultsFifteen trainees were enrolled. Three echocardiographer technicians and the course director served as experts. Across 16 unique patients, 294 ultrasound clips were acquired. For all 9 movements, the adjusted difference between trainees and experts narrowed day-to-day (p value < 0.05), suggesting ongoing improvement during training. By the last day of the course, there were no statistically significant differences between trainees and experts in translational movement, gyroscopic movement, smoothness, or total path length; yet on average trainees took 28 s (95% CI [14.7–40.3] seconds) more to acquire a clip.ConclusionsWe detected improved ultrasound probe motion economy among internal medicine trainees during a 5-day training course in cardiac POCUS using an inexpensive probe tracking device. Objectively quantifying probe motion economy may help assess a trainee’s level of proficiency in this skill and individualize their POCUS training.

Cardiac point-of-care ultrasound: Practical integration in the pediatric and neonatal intensive care settings.

Cardiac point-of-care ultrasound (POCUS) is a technology increasingly leveraged at the bedside by pediatric criticalcare and neonatology providers to identify real-time hemodynamic pathophysiology. We present a framework for (1)identifying the scope of cardiac POCUS within the clinical practice setting, (2) standardizing views for protocolizedhemodynamic assessment relevant to pediatric critical illness and (3) integrating POCUS findings for therapeuticguidance. Within the review, we also discuss practical strengths and limitations to image acquisition andinterpretation within the varied cardiac POCUS views. Finally, we explore unique considerations within the neonatalpopulation. Conclusion: Cardiac POCUS is a technology and tool that reveals important real-time information at the bedside of the criticallyill child and infant. Understanding strengths and limitations of cardiac POCUS views and protocolizing an approachto answer focused clinical questions provides a framework for training and translation to clinical care. What is Known: • Ultrasound technology is now ubiquitous among pediatric critical care and neonatology settings, and growing literature supports an expanded role in not only procedural but also diagnostic applications. • Cardiac POCUS influences provider perception of pathophysiology and changes clinical management. What is New: • Effective cardiac POCUS training and subsequent translation to clinical practice should improve when clinical questions and protocolized approaches to image acquisition are standardized within a specialty. • Cardiac POCUS views have strengths and limitations which must be recognized when assessing the hemodynamic profile of a child or neonate.

Utility of Cardiac POCUS in the Evaluation of Pediatric Chest Pain in the Emergency Department

Background/Objective:Chest pain in children is rarely caused by a life-threatening pathology. Despite the rarity of potentially life-threatening disease, most children presenting to EDs are evaluated with chest radiographs and laboratory tests without yielding helpful information that significantly changes immediate management. While the utilization of cardiac Point-of-Care Ultrasound (POCUS) by adult emergency physicians has become standard of practice, the data in pediatric emergency departments (PED) is not as robust. This study aims to describe practice patterns in the evaluation of pediatric chest pain presenting in a PED and determine clinical outcomes.&#x0D; Methods:We reviewed charts of previously healthy children aged &lt;18 years old who presented to Riley Children’s Hospital from January 2019 to July 2020 with a chief complaint of chest pain. Patients with known medical history, prior evaluations by a pediatric cardiologist, transfers from other hospital with existing workup were excluded. Patient demographics, laboratory tests and imaging ordered while in the ED, electrocardiography (EKG), consults with subspecialties, disposition and follow up plans were analyzed. We categorized clinical significance of PED interventions as minor, moderate, or major.&#x0D; Results:Out of three hundred and nineteen patients included in the study, 79.6% (254) received chest radiographs, 93.4% (298) underwent EKG, and 4.1% (13) received cardiac POCUS. The findings of these orders prompted minor interventions in 92.8% (296) of patients, moderateintervention in 4.7% (15) of patients, and major intervention in 2.5% (8) of patients.&#x0D; Conclusion and Implications:These results show a lack of use for POCUS in pediatric patients presenting with chest pain while chest radiography is preferred in the ED. Additionally, POCUS did not result in any moderate or major significant clinical outcomes.

Use of POCUS for the assessment of dehydration in pediatric patients-a narrative review.

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions. Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient's physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds.A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit

Background: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.Case Report: An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.

Diagnostic accuracy of Point Of Care UltraSound (POCUS) in clinical practice: A retrospective, emergency department based study.

Point-of-care ultrasound (POCUS) is the acquisition and interpretation of ultrasound imaging at the bedside to solve specific clinical questions based on signs and symptoms of presentation. While several studies evaluated POCUS diagnostic accuracy for a variety of clinical pictures in the emergency department (ED), only a few data are available on POCUS diagnostic accuracy performed by physicians with different POCUS skills. The objective of this research was to evaluate the diagnostic accuracy of POCUS compared to standard diagnostic imaging in the ED. This was a retrospective study conducted in the ED of a third-level university hospital. Patients who underwent cardiac, thoracic, abdominal, or venous lower limb POCUS and a standard imaging examination between June 2021 and January 2022 were included. 1047 patients were screened, and 844 patients included. A total of 933 POCUS was included (102, 12.09%, cardiac; 466, 55.21%, thoracic; 336, 39.8%, abdominal; 29, 3.44%, lower limb venous POCUS), accounting for 2029 examinations. POCUS demonstrated 96.6% (95% CI 95.72-97.34) accuracy, 47.73 (95% CI 33.64-67.72) +LR, 0.09 (95% CI 0.06-0.12) -LR. +LR was greater than 10 for all investigations but for hydronephrosis (5.8), and -LR never exceeded 0.4. POCUS exhibited high diagnostic accuracy for virtually all conditions when performed by emergency department physicians.

Image quality and technical limitations in emergency department cardiac point-of-care ultrasound: A retrospective cohort study.

To assess the image quality and common technical limitations seen on cardiac point-of-care ultrasound (POCUS) performed and archived in a single New Zealand ED. A retrospective cohort study of clinically indicated cardiac POCUS, archived from 1 October 2019 to 20 May 2020. Archived examinations were retrospectively reviewed by an ED POCUS expert, and an expert cardiac sonographer to determine diagnostic image quality, technical limitations present and opportunities for image quality improvement. Image quality of credentialed examinations was compared to uncredentialed examinations and examinations that were undocumented in the medical record. A total of 211 cardiac POCUS examinations were included. The impact of image quality on diagnostic interpretation was only documented in <2% of examinations. There was no difference in median global image quality scores for uncredentialed and credentialed examinations (8.5 vs 9, P = 0.55) and median score for undocumented examinations (5.5) was lower than credentialed examinations (P < 0.01). Common technical limitations identified were off-axis imaging and artefacts limiting image quality. In the present study of clinically indicated cardiac POCUS, low image quality was common but the impact of image quality on diagnostic interpretation was very rarely documented in the medical record. Local quality assurance and training should be directed at credentialed and uncredentialed clinicians including strategies to improve off-axis imaging and managing artefacts where possible. Standardised documentation of image quality that may impact diagnostic accuracy should be encouraged.

1762. Clinical application of handheld ultrasound devices during the 2022 Sudan Virus disease Ebola outbreak in Uganda

Abstract Background The fluid status and causes of respiratory failure in patients with Ebola disease can be challenging to determine due to concomitant severe diarrhea, vascular leakage, and multiorgan failure. Point-of-care ultrasound (POCUS) could guide fluid resuscitation for patients in resource-limited settings. We present the clinical application of POCUS in the 2022 Sudan Virus disease Ebola outbreak in Uganda. Figure. Ultrasound findings from patient 2. 2A: Discrete B lines observed with an irregular pleural line; 2B: Inferior vena cava collapsibility &amp;lt;50% suggestive of adequate fluid resuscitation; 2C: parasternal short cardiac view with small pericardial effusion identified; 2D: apical cardiac view with small pericardial effusion redemonstrated. Methods A clinical research team in Fort Portal, Uganda was trained in advanced Infection Prevention and Control (IPC) to care for patients with Ebola disease and in POCUS for septic shock. The clinical team learned a standardized lung and cardiac critical care ultrasound approach to evaluate patients in septic shock. The scanning procedure was used during the care of 6 patients with confirmed Sudan virus disease within 2 weeks of outbreak declaration to make critical patient care decisions like fluid management. Chest X-ray services and mechanical ventilation were not accessible. A handheld Philips Lumify device was kept in the biocontainment area and was used in full personal protective equipment. Scanning procedures included 12-zone lung ultrasound and 4-view cardiac ultrasound scans to determine causes of respiratory disease and evaluate fluid status. Results Among 6 patients (age range 27 to 58 years; 1/6 female), 5/6 were in their third week of illness, and 1/6 was in his second week of illness. Lung ultrasound abnormalities included discrete B-lines (5/6 patients), confluent B-lines (1/6), irregular pleural lines (3/6 patients), and subpleural consolidations (1/6 patients). Two participants in respiratory distress had cardiac POCUS. Both had hyperdynamic left ventricular function and one had a small pericardial effusion (Figure). One patient had inferior vena cava (IVC) collapsibility &amp;lt; 50% (1.5 cm diameter), and another with a &amp;gt;50% IVC collapsibility (1.3 cm diameter). These findings contributed to a decision to continue fluid resuscitation. Conclusion Portable handheld ultrasound devices identified previously undescribed ultrasound features of Sudan virus disease. POCUS helped determine causes of respiratory failure and guided fluid resuscitation in a biocontainment ward without access to mechanical ventilation. Disclosures All Authors: No reported disclosures

Acute Type A Aortic Dissection Diagnosed by POCUS in a 29-year-old Man

Aortic dissection (AD) is a medical emergency with a poor prognosis if not recognized early and treated promptly. In this setting, clinical data may be equivocal, while electrocardiogram, laboratory tests, and chest radiography often show nonspecific findings. In contrast, cardiac point of care ultrasound (POCUS) has proven useful in the diagnosis and detection of complications of AD. We present the case of a 29-year-old man with marfanoid habitus presenting with chest pain and acute heart failure, in whom cardiac POCUS aided in the rapid diagnosis of type A AD and pulmonary edema. POCUS contributed to optimizing the medical treatment and allowed for early activation of the surgical team.

Training of Non-expert Users Using Remotely Delivered, Point-of-Care Tele-Ultrasound: A Proof-of-Concept Study in 2 Canadian Communities.

Many physicians, particularly those practicing in remote regions, lack training opportunities to develop point-of-care ultrasound (POCUS) skills. This pretest-posttest study quantified the skill improvement of learners after participating in a virtual training program that used real-time, remotely delivered point-of-care tele-ultrasound (tele-POCUS) for teaching and learner feedback provision. Ten physicians practicing in an urban tertiary (Kingston, Ontario, Canada, n = 6) or remote care center (Moose Factory, Ontario, Canada, n = 4) completed a 3-week educational program that consisted of e-learning module review, independent image acquisition practice, and expert-guided tele-POCUS consultations. Pretraining and posttraining assessments were performed to evaluate skill enhancement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS using a 5-point Likert scale. A total of 76 tele-POCUS consultations were performed during the study period. Significant improvements in image quality were noted following remotely delivered mentorship and guidance (all P < 0.01). In cardiac POCUS, pretraining and posttraining comparisons noted significant improvements in image acquisition (means, 2.69-4.33; P < 0.02), quality (means, 2.40-4.03; P < 0.01), and interpretation (means, 2.50-4.40; P < 0.02). In lung/pleura POCUS, significant improvements in image acquisition (means, 3.00-4.43; P < 0.01), quality (means, 3.23-4.37; P < 0.01), and interpretation (means, 3.00-4.40; P < 0.01) were demonstrated. Introductory ultrasound can be taught to novice users using a virtual, live-streamed training format with tele-POCUS while demonstrating significant enhancement in imaging skills.

Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review.

The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology. Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED. While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.

Test Characteristics of Cardiac Point-of-Care Ultrasound in Children With Preexisting Cardiac Conditions.

The aim of the study is to assess diagnostic performance of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians in children with preexisting cardiac disease. We evaluated the use of cardiac POCUS performed by PEM physicians among a convenience sample of children with preexisting cardiac disease presenting to a tertiary care pediatric ED. We assessed patient characteristics and the indication for POCUS. The test characteristics of the sonologist interpretation for the assessment of both pericardial effusion as well as left ventricular systolic dysfunction were compared with expert POCUS review by PEM physicians with POCUS fellowship training. A total of 104 children with preexisting cardiac disease underwent cardiac POCUS examinations between July 2015 and December 2017. Among children with preexisting cardiac disease, structural defects were present in 72%, acquired conditions in 22%, and arrhythmias in 13% of patients. Cardiac POCUS was most frequently obtained because of chest pain (55%), dyspnea (18%), tachycardia (17%), and syncope (10%). Cardiac POCUS interpretation compared with expert review had a sensitivity of 100% (95% confidence interval [CI], 85.7-100) for pericardial effusion and 100% (95% CI, 71.5-100) for left ventricular systolic dysfunction; specificity was 97.5% (95% CI, 91.3.1-99.7) for pericardial effusion and 98.9% (95% CI, 93.8-99.8) for left ventricular systolic dysfunction. Cardiac POCUS demonstrates good sensitivity and specificity in diagnosing pericardial effusion and left ventricular systolic dysfunction in children with preexisting cardiac conditions when technically adequate studies are obtained. These findings support future studies of cardiac POCUS in children with preexisting cardiac conditions presenting to the ED.

Learning curves for point-of-care ultrasound image acquisition for novice learners in a longitudinal curriculum

BackgroundA learning curve is graphical representation of the relationship between effort, such as repetitive practice or time spent, and the resultant learning based on specific outcomes. Group learning curves provide information for designing educational interventions or assessments. Little is known regarding the learning curves for Point-of-Care Ultrasound (POCUS) psychomotor skill acquisition of novice learners. As POCUS inclusion in education increases, a more thorough understanding of this topic is needed to allow educators to make informed decisions regarding curriculum design. The purpose of this research study is to: (A) define the psychomotor skill acquisition learning curves of novice Physician Assistant students, and (B) analyze the learning curves for the individual image quality components of depth, gain and tomographic axis.ResultsA total of 2695 examinations were completed and reviewed. On group-level learning curves, plateau points were noted to be similar for abdominal, lung, and renal systems around 17 examinations. Bladder scores were consistently good across all exam components from the start of the curriculum. For cardiac exams, students improved even after 25 exams. Learning curves for tomographic axis (angle of intersection of the ultrasound with the structure of interest) were longer than those for depth and gain. Learning curves for axis were longer than those for depth and gain.ConclusionBladder POCUS skills can be rapidly acquired and have the shortest learning curve. Abdominal aorta, kidney, and lung POCUS have similar learning curves, while cardiac POCUS has the longest learning curve. Analysis of learning curves for depth, axis, and gain demonstrates that axis has the longest learner curve of the three components of image quality. This finding has previously not been reported and provides a more nuanced understanding of psychomotor skill learning for novices. Learners might benefit from educators paying particular attention to optimizing the unique tomographic axis for each organ system.