Point-of-care Ultrasound In Emergency Department Research Articles

Interobserver agreement of an ED PoCUS video training dataset of normal appendix and appendicitis in children

BackgroundEducational video datasets can be an effective method for training in emergency department (ED) point-of-care ultrasound (PoCUS). A video dataset for normal appendix and appendicitis in children using ED PoCUS images was developed to assess interobserver agreement, as measured by Cohen’s Kappa on key sonographic findings.MethodsThree sets of 25 ED PoCUS videos were selected and curated from pediatric patients with normal appendix and acute appendicitis. Four participant ED sonologist-physicians were trained on the first set of 25 videos showing normal appendix or normal bowel in patients without appendicitis to note if normal appendix was seen in any part or in it’s entirety from tip-to-cecum. They were then tested on the second set of similar videos. A third set of 25 videos from patients who had appendicitis where participant sonologists were asked to note if appendicitis was present or absent, with and without appendicolith or perforation. Cohen’s Kappa was calculated in aggregate and stratified by experience vs. novice against a senior sonologist-physician aware of all patient outcomes for visualization of: 1. any part of normal appendix, 2. normal appendix visualized from tip to cecum 3. any part of appendicitis, 4. appendicolith, 5. appendiceal perforation.ResultsCohen’s Kappa for any part of normal appendix, 0.71, 95% CI (0.58–0.85); normal appendix tip-to-cecum, 0.43, 95% CI (0.19–0.67), appendicitis, 0.53, 95%CI (0.34–0.70), appendicolith, 0.63, 95%CI (0.43–0.84), perforated appendicitis, 0.46, 95%CI (0.22–0.70). Stratified by experienced vs. novice: any part of normal appendix, 0.75 vs. 0.68; normal appendix tip-to-cecum, 0.50 vs. 0.36; appendicitis, 0.78 vs. 0.31; appendicolith, 0.75 vs. 0.5; perforated appendicitis, 0.5 vs 0.42.ConclusionsThis educational video dataset may be used to train sonologist-physicians in ED PoCUS scanning for normal appendix and appendicitis in children. Sonologist experience affected interobserver agreement with respect to visualization of entire normal appendix and appendicitis.

Evaluation of hand infections in the emergency department using point-of-care ultrasound.

We aimed to evaluate the utility of point-of-care ultrasound (POCUS) in the assessment of hand infections that present to the emergency department (ED) and its impact on medical decision making and patient management. We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections (SSTI) of the hand between December 2015 and December 2021. Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand. We then reviewed patients' electronic health records (EHR) for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, consultations, impact of POCUS on patient care and final disposition. We included a total of 50 cases (28 male, 22 female) in the final analysis. The most common presenting symptoms and exam findings were pain (100%), swelling (90%), and erythema (74%). The most common sonographic findings were edema (76%), soft tissue swelling (78%), and fluid surrounding the tendon (57%). POCUS was used in medical decision making 68% of the time (n=34), with the use of POCUS leading to changes in management 38% of the time (n=19). POCUS use led to early antibiotic use (11/19), early consultation (10/19), and led to the performance of a required procedure (8/19). The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times, abscess 12/16 times, and cellulitis 14/20 times. POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.

Quantifying Clinically Meaningful Point-of-Care Ultrasound Interpretation Discrepancies Using an Emergency Department Quality Assurance Program.

Emergency medicine professional associations recommend that quality assurance (QA) programs be implemented wherever emergency department (ED) point-of-care ultrasound (POCUS) is in use. The purpose of this study is to identify the rate of clinically meaningful interpretation discrepancies between initial ED POCUS interpretation and a gold standard using a QA program in a Canadian academic ED. All POCUS examinations completed in our ED are subject to a QA process. The results of all POCUS examinations undergoing this process from July 1, 2014, to June 30, 2015, were retrospectively reviewed. Four blinded abstractors collected data with a standardized tool after a training session. Information regarding patient demographics, POCUS indication, emergency physician initial POCUS interpretation, physician POCUS expertise, the presence of an interpretation discrepancy, and whether the discrepancy was clinically meaningful was abstracted. The proportion of interpretation discrepancies, clinically meaningful discrepancies, discrepancies requiring remedial action, and differences in discrepancy rates between non-expert and expert sonographers were analyzed. A total of 2,869 POCUS studies were included for review, with 2,668 in the final data set after exclusions. In total, only 1.4% of all scans contained an interpretation discrepancy. The rate of clinically meaningful discrepancies was 0.5%, and the rate of scans requiring remedial action was 0.1%. Overall, 85.5% of all scans were performed by four POCUS expert physicians, with the remainder by a non-expert. Scans performed by non-expert sonographers were significantly more prone to discrepancies than those performed by experts. No single scan indication was more prone to discrepancy. The overall ED POCUS interpretation discrepancy rate and clinically meaningful discrepancy rate identified using our QA process were very low. The findings are limited by the small group of expert sonographers completing most scans.

Point-of-care ultrasound: impact on emergency department length of stay for suspected lower extremity DVT.

Point-of-care ultrasound (POCUS) has demonstrated excellent sensitivity and specificity for the diagnosis of DVT in the emergency department (ED). Before POCUS became widespread, patients underwent radiology department comprehensive lower extremity venous duplex ultrasounds (RADUS) which may be associated witha prolonged length of stay. The goal of this study is to evaluate the impact of POCUS on ED arrival to disposition (ATD) time for patients presenting to the ED with suspected lower extremity DVT. This is a retrospective chart analysis of ED visits to an urban, university-affiliated community hospital from January 2019 to December 2020. This study compared ATD between patients who underwent POCUS by an emergency medicine physician and RADUS by the radiology department. In total, 1204 patients underwent POCUS, and 1582 patients were evaluated with RADUS. The POCUS mean ATD was 313 ± 16.8min compared to the RADUS arm average of 323 ± 57.9min (p = 0.56). Order to disposition time (OTD) was prolonged among the RADUS group relative to POCUS. ATD was significantly reduced in the POCUS subgroup of patients presenting during night shift when RADUS was not available, 326 ± 28.2min versus 630 ± 109min (p < 0.05). ED POCUS scans decrease the amount of time between order placement and disposition when compared to RADUS. POCUS significantly decreases length of stay in the ED when RADUS is not available.

Emergency Department Point-of-Care Echocardiography and Lung Ultrasound in Predicting COVID-19 Severity.

We sought to determine if point-of-care ultrasound (POCUS) performed on patients with COVID-19 in the emergency department (ED) can help predict disease course, severity, or identify complications. This was a retrospective cohort study of adult ED patients who tested positive for COVID-19 at hospital admission or within 2 weeks of presentation and received heart or lung POCUS. Clips were reviewed for presence of decreased left ventricular ejection fraction (LVEF), right ventricular dilation, presence of B-lines, and pleural line abnormalities. Patients with worsening hypoxemic respiratory failure or shock requiring higher level of care and patients who expired were considered to have developed severe COVID-19. Regression analysis was performed to determine if there was a correlation between ED POCUS findings and development of severe COVID-19. A total of 155 patients met study criteria; 148 patients had documented cardiac views and 116 patients had documented lung views (113 with both). Mean age was 66.5 years old (±18.6) and 53% of subjects were female. Subjects with decreased LVEF that was not previously documented had increased odds of having severe COVID during their hospitalization compared to those with old or no dysfunction (OR 5.66, 95% CI: 1.55-19.95, P=.08). The presence of pleural line abnormalities was also predictive for development of severe COVID (OR 2.68, 95% CI: 1.04-6.92, P=.04). POCUS findings of previously unidentified decreased LVEF and pleural line abnormalities in patients with COVID-19 evaluated in the ED were correlated to a more severe clinical course and worse prognosis.

354 Diagnostic Utility of Point-of-Care Ultrasound in the Evaluation of Necrotizing Soft Tissue Infections

Necrotizing soft-tissue infections (NSTIs) are potentially life-threatening medical emergencies that require rapid identification and aggressive treatment. Emergency physicians are utilizing point-of-care ultrasound (POCUS) for a wide variety of applications. The objective of this study was to determine the diagnostic utility of POCUS in the evaluation of patients with suspected SSTI in the emergency department (ED). This was a retrospective review of ED patients presenting to an academic center with symptoms suspicious for NSTI and received a POCUS. POCUS findings were collected from ED POCUS archiving database. Medical records were then reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, operative intervention, disposition, and final diagnosis. POCUS findings were compared with LRINEC scores and operative findings. A total of 65 patients (15 females, 50 males; mean age, 55 years +/- 13.6) were included in this study. Patients presented with pain (46/65), swelling (33/65), redness (28/65) and open wound (21/65). Most common symptomatic sites were feet (27%) and upper arm (21%). Nineteen patients reported injection drug use. In triage, 53% patients were tachycardiac and 5 patients were hypotensive. Pain out of proportion was documented in 3 patients. Based on operative findings, 38% (25/65) patients were found to have NSTI. All patients with final diagnosis of NSTI had sonographic findings (hypoechoic fluid tracking along the deep fascial layers, fluid accumulation > 4 mm in depth along the deep fascial layers, air in the soft tissues) indicating NSTI on POCUS. In addition, POCUS demonstrated abscess (28%), cellulitis (62%), pyomyositis (2.9%) and superficial Fasciitis (27%). Subcutaneous gas was noted in 11 patients. Early surgical consultation was obtained in these eleven patients prior to laboratory results and additional imaging studies. Six patients with LRINEC Score < 6 were found to have NSTI and all 6 patients had sonographic findings suggestive of NSTI on POCUS. Only one of these patients had abnormal vital signs in triage. Our study suggests that POCUS can be a useful adjunct in the evaluation of patients with NSTI. Integration of POCUS findings into LRINEC Score could improve risk stratification.

353 Point-of-Care Ultrasound in the Evaluation of Rattlesnake Envenomation

To our knowledge, no prior studies investigated the role of point-of-care ultrasound (POCUS) in the evaluation of rattlesnake envenomation. The objective of this study was to determine the utility of POCUS in the management of rattlesnake envenomation in the emergency department (ED). This was a retrospective review of patients presenting to an academic ED with rattlesnake bite and received a POCUS examination after initial clinical assessment. Proximal progression of symptoms and signs in the affected extremity was monitored clinically and repeat POCUS examinations of the extremity were performed. POCUS findings were collected from ED POCUS database. Medical records were then reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, and disposition. The proportion of patients whose treatment plan was altered by the addition of POCUS findings was determined. A total of 21 patients (mean age 48 years ± 15 (SD); 14 males, 7 females) were included in this study. All patients presented with pain, swelling and tenderness at the site of bite (16-lower extremity, 5-upper extremity). On initial POCUS examination, all patients except one case were noted to have subcutaneous edema at the location of snake bite. Twelve patients were also noted to have cobblestoning on initial POCUS. Myokymia was visualized on initial POCUS in 2 patients. On repeat assessments, POCUS demonstrated subcutaneous edema and cobblestoning more proximally than what was determined and marked by treating emergency physicians in 16 patients. Four patients received additional doses of antivenom based on POCUS findings. The one patient who did not have any sonographic findings on initial POCUS was eventually determined to have dry bite by the toxicologist. Patients with myokymia had a complicated hospital course with thrombocytopenia and deterioration of hemodynamic status. Despite limited numbers, our study suggests that POCUS can be a useful adjunct in the evaluation of patients with rattlesnake bite. Ultrasound appears to be more sensitive than clinical assessment in detecting proximal progression of effects of venom and can potentially guide management. Our ongoing prospective study will further define the role of POCUS in the treatment of rattlesnake envenomation.

P041: Point-of-care ultrasound utilization and monetary outcomes (POCUMON) study

Introduction: Point-of-care ultrasound (POCUS) is an integral tool in the modern emergency physician's toolkit. Evidence suggests many imaging and lab investigations are ordered without true medical indications; it is unknown how POCUS utilization impacts health care costs at a patient level. The purpose of this study was to assess whether POCUS use in the emergency department (ED) was associated with cost savings via decreased laboratory and radiographic testing. Methods: POCUMON is a single-center, prospective pilot study. The participants were a convenience sample of ED staff physicians and PGY-5 Emergency Medicine (EM) residents working in the ED from July-October 2019. Physicians who used POCUS as part of their assessment had the cost of their patient investigation plans compared with those proposed by a control group of ED physicians simultaneously on-shift. The control group was blinded to the POCUS findings but had access to the patient and medical record. The lab investigations and imaging studies ordered by both groups were recorded with respective costs. Data were analyzed using a paired T-test, with sub-group analyses. Ethics approval was obtained from the Queen's University HSREB (No.6026732). Results: 50 patient assessments using POCUS were captured in the study period. 76% of patient assessments were performed by EM staff physicians; 94% of control assessments were provided by EM staff physicians. Patient chief complaints included abdominal pain (7), chest pain/dyspnea (10), flank pain (3), pregnancy concerns (4), trauma (7), extremity complaints (4), back pain (3), and other (12). The POCUS group had a trend for lower number of laboratory tests (4.7 ± 0.44 vs 5.22 ± 0.39; p = 0.28) and imaging studies (0.94 ± 0.14 vs 1.1 ± 0.11; p = 0.33). Overall health care costs were similar in both groups, with a trend to cost savings in the POCUS group ($142.00 ± 15.44 vs $174.60 ± 17.00; p = 0.12). Subgrouping identified significant cost savings in the POCUS group for patients with a chief complaint of flank pain ($43.64 vs $248.82, p = 0.01). Conclusion: POCUS use was not associated with significant health care cost savings. ED POCUS usage did see a trend towards decreased laboratory and imaging investigations. Patients presenting with flank pain had significantly lower expenditures associated with their visit when POCUS was incorporated into their assessment. Large scale prospective studies are needed to investigate if POCUS is associated with cost-savings in ED patients.

Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal.

PurposePoint-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick’s 4 steps of evaluating training outcomes.Materials and MethodsWe conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored.ResultsA total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75–17.75) and 24.5 (22.25–25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields.ConclusionThe participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants’ skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.

24 The ULTrA Method: Data-Driven Approach to Point-of-Care Ultrasound Machine Upgrade and Replacement

Proactive management of point-of-care ultrasound (POCUS) equipment is critical for operations in the modern emergency department (ED). While abundant literature exists surrounding the use of POCUS in the ED, formal recommendations for machine upgrade, maintenance, and renewal have not yet been described. This pilot study proposes a novel method for data-driven, routine assessment of ED POCUS machines to guide upgrade and replacement decisions. In our tertiary academic hospital ED, we evaluated the clinical effectiveness of nine ultrasound devices of four different models in five patient care areas over one year. The ULTrA scoring system assigned up to 5 points in each of the four categories: Utilization rate (U) (number of scans performed per device); Likeability (L), graded by eight POCUS faculty members and ultrasound fellows; machine Trustworthiness (Tr), based on retroactive review of down-time required for troubleshooting or repair; and device Age (A). The Score is shown in Table 1. During the study period, 67,942 scans were completed. Utilization for a single machine ranged from 43% of all scans to <1% of all scans. Likability scores ranged from 3-5 (median 4). Trustworthiness ranged from 3-5 (median 4). Age ranged from 1-9 years (median 6 years). ULTrA scores ranged from 12 to 19 (median 14), with one model (A-i) earning the three highest scores (19, 18, 17) and another model (B-i) earning the three lowest scores (12, 12, 12). Regardless of machine make/model, likability, trustworthiness, and age, utilization was highest for machines primarily located in high-acuity areas of the adult ED when compared with low-acuity areas. “Acute” machines contributed to 52% of all scans, while “Pediatric” machines contributing to only 1%. In this study, we describe the ULTrA model for data-driven, routine assessment of ultrasound devices to forecast need for near-future machine upgrades or replacement. Our findings propose that the ULTrA scoring model as a mostly objective score to identify underperforming devices. This composite score may be used instead of individual proxies for clinical effectiveness, such as age, utilization, or provider preference on their own.

Prevalence and utility of point-of-care ultrasound in the emergency department: A prospective observational study.

An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.

Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic intussusception

BackgroundIdentification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS. MethodsWe conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated. ResultsED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35–76 months) for SB-SBI and 8 months (IQR 5.8–13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68–1.0). ConclusionsSB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.

Evaluation of a new goal-directed training curriculum for point-of-care ultrasound in the emergency department: impact on physician self-confidence and ultrasound skills

PurposeDeveloping countries need effective and efficient training curriculum for the point-of-care ultrasound (POCUS) in the emergency department (ED). We have developed a new goal-directed training curriculum focusing on critical POCUS procedures used in ED.MethodsTo evaluate the impact of the new POCUS curriculum on ED physicians’ performance/self-confidence, we carried out a quasi-experimental trial at ED training center of Peking Union Medical College Hospital, in which we trained two groups of physicians using either traditional curriculum or the new goal-directed curriculum. We measured the confidence in performing Focused Assessment with Sonography in Trauma, thoracic, vascular, ultrasound-guided puncture, echocardiography and undifferentiated shock diagnostic ultrasound at baseline, training completion and 1 month after training. We also measured the performance skills at the time of training completion. The relative value of the new curriculum was evaluated by differences in the confidence and performance measurements, with control for baseline measurements and confounding characteristics in univariate analyses and multivariate linear regression models.ResultsAfter training, both groups of trainees reported significantly increased self-confidence in performing POCUS as compared with baseline. Trainees with the new curriculum had statistically significant higher self-confidence increase and performance scores (p < 0.05), e.g., increase in confidence for diagnosis of undifferentiated shock at training completion = 3.14 vs. 1.85, 1 month after training = 2.22 vs. 1.56, for new and traditional curriculum, respectively. The new curriculum also resulted in a higher number of shock POCUS done within 1 month after training: 1.73 vs. 0, and higher overall performance scores: 165 vs. 113. The findings were robust when controlling for imbalanced baseline characteristics in multivariate regression models.ConclusionWe conclude that a goal-directed, intensive but brief ED POCUS curriculum significantly increases trainee self-confidence, performance, and promote trainees to perform more procedures.

Survey on the use of point-of-care ultrasound detection in 300 emergency departments of tertiary hospital in China in 2018

To investigate the possession of ultrasound equipment and use of point-of-care ultrasound (POCUS) in emergency department of tertiary hospitals in China to figure out the present condition of POCUS in the emergency department. Questionnaire survey was performed through the internet, which included equipment possession, usage, and the sterile technique of the probe in the emergency department of tertiary hospitals. Between September and December in 2018, a total of 2 994 questionnaires link was clicked, and 718 survey responses were collected. After removing duplicated and non-tertiary hospitals questionnaires, the final questionnaire survey covered 300 tertiary hospitals, of which 250 were tertiary A hospitals (83.3%). The number of emergency department which own bedside ultrasound machine was 173 (57.7%), 40.6% (122) of the departments had only one ultrasonic machine. The main sources of equipment were new bought machines (119, 68.8%), given (38, 22.0%) or rented old machines from the ultrasound department (42, 24.3%). None of the emergency physicians in 92 (30.7%) departments mastered the POCUS skills, and 52.7% of the response hospital had less than a quarter emergency physicians grasp the skills. Fees of the POCUS could be charged in 52 (30.1%) of them. The main methods to clean or sterilize the probes were to wipe the probe by cleaning dry paper (97, 56.1%), sterile wet paper (69, 39.9%) or special probe disinfector (23, 13.3%), and used probe protective sleeve and sterile gel (12, 6.9%) as necessary; 79 (45.7%) departments had no conventional probe disinfection measures. When the ultrasonic was used to guide the punctures, the prevention of infection policies were the sterile gloves and saline (106, 61.3%), disposable probe protective sleeve and sterile gel (55, 31.8%). The propagation of POCUS in emergency department is needed to develop in tertiary hospitals in China. The right way to clean the probes need to be emphasized.

Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology.

To evaluate the utilization of point-of-care ultrasound (POCUS) for the assessment of emergency department (ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED. This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED. A total of 264 subjects (92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the final analysis. Most common symptomatic sites were knee (31.8%) and ankle (16.3%). Joint effusion was the most common finding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them (73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records. Our study findings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.

Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department

BackgroundThis review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis. MethodsA PubMed literature search was conducted for articles published between January 1, 1996 and May 31, 2017 and limited to human clinical trials written in English with relevant keywords. High-quality studies identified then underwent a structured review. Recommendations herein are made based on the literature review. ResultsTwo hundred seventy-two abstracts fulfilling the search criteria were screened and 10 appropriate articles were rigorously reviewed in detail. There were 8 prospective studies and 2 retrospective studies. Only 1 of them was a multi-institutional randomized trial. POCUS performed in the emergency department (ED) is moderately sensitive and specific in making the diagnosis of urolithiasis in symptomatic patients. Suspected urolithiasis patients evaluated initially with ED POCUS have complication rates compatible with those evaluated initially with computed tomography. ConclusionsPOCUS has moderate accuracy in making the diagnosis of urolithiasis. Nevertheless, it may be safely used as a first line of imaging in ED patients with suspected symptomatic urolithiaisis.

Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis.

Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+= 4.81, 95% confidence interval [CI]= 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+= 7.64, 95% CI= 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+= 3.52, 95% CI= 2.65-4.68). Among different PAS cutoff points, PAS≥ 9 (LR+= 5.26, 95% CI= 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA inpatients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI= 6.24-13.28) and LR- of 0.17 (95% CI= 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.