Point-of-care Ultrasound Assessment Research Articles

Deep learning models for interpretation of point of care ultrasound in military working dogs.

Military working dogs (MWDs) are essential for military operations in a wide range of missions. With this pivotal role, MWDs can become casualties requiring specialized veterinary care that may not always be available far forward on the battlefield. Some injuries such as pneumothorax, hemothorax, or abdominal hemorrhage can be diagnosed using point of care ultrasound (POCUS) such as the Global FAST® exam. This presents a unique opportunity for artificial intelligence (AI) to aid in the interpretation of ultrasound images. In this article, deep learning classification neural networks were developed for POCUS assessment in MWDs. Images were collected in five MWDs under general anesthesia or deep sedation for all scan points in the Global FAST® exam. For representative injuries, a cadaver model was used from which positive and negative injury images were captured. A total of 327 ultrasound clips were captured and split across scan points for training three different AI network architectures: MobileNetV2, DarkNet-19, and ShrapML. Gradient class activation mapping (GradCAM) overlays were generated for representative images to better explain AI predictions. Performance of AI models reached over 82% accuracy for all scan points. The model with the highest performance was trained with the MobileNetV2 network for the cystocolic scan point achieving 99.8% accuracy. Across all trained networks the diaphragmatic hepatorenal scan point had the best overall performance. However, GradCAM overlays showed that the models with highest accuracy, like MobileNetV2, were not always identifying relevant features. Conversely, the GradCAM heatmaps for ShrapML show general agreement with regions most indicative of fluid accumulation. Overall, the AI models developed can automate POCUS predictions in MWDs. Preliminarily, ShrapML had the strongest performance and prediction rate paired with accurately tracking fluid accumulation sites, making it the most suitable option for eventual real-time deployment with ultrasound systems. Further integration of this technology with imaging technologies will expand use of POCUS-based triage of MWDs.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

IntroductionThis paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. MethodsPatients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. ResultsA total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. ConclusionsPatients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Point-of-Care Arterio-Venous Fistula Ultrasound in the Outpatient Hemodialysis Unit-A Survey on the Nurses' Perspective.

The preservation of complication-free arterio-venous fistulas (AVF) for long-term hemodialysis (HD) use is associated with better overall patient outcomes, which is why this is a current goal in any HD center. Point-of-care ultrasound (POCUS) for in-center AVF assessment has proven its benefits in the identification of vascular access (VA) complications and as an additional tool to avoid blind cannulation. The current study aims to assess the change in the HD nurses' perceptions regarding AVF POCUS use in the HD center. The nursing staff anonymously answered a Likert scale questionnaire with five questions related to various aspects of AVF POCUS utility shortly after the technique had been implemented and at a 5-year follow-up. The results showed an overall positive attitude toward this method, both at implementation and at follow-up, with no statistically significant score changes for four out of the five items assessed. However, we found a statistically significant reduction in the nurses' cannulation confidence scores at the 5-year follow-up (p < 0.01). Overall, AVF POCUS implementation is regarded as a useful tool, with major benefits both for the patient and for the medical team. The current study results aim to support the introduction of AVF POCUS assessment as a standard practice from the nursing staff's viewpoint. This study was not registered.

The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department—an observational study

BackgroundEndotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As point-of-care ultrasound (POCUS) assessment of airway parameters does not require patients to perform any mandatory action, ultrasound may become the potential first-line noninvasive airway assessment tool in the emergency department (ED). The use of POCUS in the ED has not been sufficiently studied. Using POCUS in airway assessment for predicting difficult intubation may be the next step in successful airway management.MethodologyThe study was an observational study conducted at the ED of the All India Institute of Medical Sciences (Rishikesh). The treating emergency physician recorded the patient history and systemic examination along with an indication for intubation. The POCUS assessment of airway parameters pre-epiglottis to epiglottic vocal cord ratio (Pre-E/E-VC), tongue thickness, hyomental distance, and distance from skin to the hyoid bone was performed by the study investigator. During laryngoscopy, Cormack-Lehane (CL) grading was assessed. The data was entered and analyzed.ResultsSeventy patients who required intubation in the ED were enrolled in the study. Among the study population, 48.6%, 28.6%, 14.3%, 1.4%, and 7.1% were classified with the following CL grading: 1, 2a, 2b, 3a, and 3b, respectively. At a cutoff of ≥ 1.86, Pre-E/E-VC predicts difficult laryngoscopy (AUC 0.835) with a sensitivity of 83% and a specificity of 94%. At a cutoff of ≥ 5.98 cm, tongue thickness predicts difficult laryngoscopy (AUC 0.78) with a sensitivity of 83% and a specificity of 88%. At a cutoff of hyomental distance ≤ 6 cm, it predicts difficult laryngoscopy with a sensitivity of 83% and a specificity of 88%. All parameters can act as a promising tool for predicting difficult laryngoscopy, with the single best parameter being Pre-E/E-VC.ConclusionAssessment of the airway with POCUS may be helpful to the emergency physician when the clinical airway assessment parameters fail to predict difficult laryngoscopy as most patients requiring intubation are uncooperative. Assessment of the parameters in our study Pre-E/E-VC, tongue thickness, and hyomental distance can act as a promising tool for predicting difficult laryngoscopy in the emergency scenario.

A Narrative Review of Point of Care Ultrasound Assessment of the Optic Nerve in Emergency Medicine

Point of care ultrasound (POCUS) of the optic nerve is easy to learn and has great diagnostic potential. Within emergency medicine, research has primarily focused on its use for the assessment of increased intracranial pressure, but many other applications exist, though the literature is heterogeneous and largely observational. This narrative review describes the principles of POCUS of the optic nerve including anatomy and scanning technique, as well as a summary of its best studied clinical applications of relevance in emergency medicine: increased intracranial pressure, idiopathic intracranial hypertension, optic neuritis, acute mountain sickness, and pediatric intracranial pressure assessment. In many of these applications, sonographic optic nerve sheath diameter (ONSD) has moderately high sensitivity and specificity, but the supporting studies are heterogeneous. Further studies should focus on standardization of the measurement of ONSD, establishment of consistent diagnostic thresholds for elevated intracranial pressure, and automation of ONSD measurement.

Neurogenic stunned myocardium resulting from surgical brainstem handling during resection of paediatric recurrent medulloblastoma—a possible brain heart interaction

Neurogenic stunned myocardium (NSM) is characterised by an acute onset cardiac dysfunction following an acute neurological insult which mimics acute coronary syndrome. A 12-year-old male child was admitted to the neuro-intensive care unit (NICU) following midline suboccipital craniotomy and resection of recurrent medulloblastoma. Postoperatively, in NICU, he developed tachycardia and hypotension, which was unresponsive to fluid challenge requiring norepinephrine infusion. Intraoperatively, during tumour resection from the dorsal medulla, episodes of hypertension and bradycardia were observed. Intraoperative blood loss was adequately managed with a stable hemodynamic profile without postoperative anaemia. An electrocardiogram showed sinus tachycardia with T wave inversion, and blood investigation revealed elevated cardiac troponin T levels. Point of care ultrasound (POCUS) of heart and lung showed features of NSM. Infusion dobutamine was added to achieve a target mean arterial pressure of 65mm Hg with concomitant furosemide infusion and fluid restriction. Daily POCUS assessment of cardiac contractility and volume status was done. The patient was weaned from vasoactive drugs and ventilator following improvement of cardiac function and was discharged from NICU after 17days. NSM results from the excessive release of catecholamines following stimulation of trigger zones in the brain. To date, a handful of cases of pediatric NSM following primary brain tumour are reported where hydrocephalus resulted in trigger zone activation. In this presented case, direct brain stem stimulation during tumour resection might have triggered NSM. Irrespective of the cause, timely diagnosis and execution of supportive management in our patient resulted in a positive outcome.

Point of Care Ultrasound Assessment of Hypoxemia

Point of care ultrasound has the advantages of rapid, real-time and radiation-free, and has been widely used in clinical practice. The combination of Bedside Lung Ultrasound in Emergency Protocol (BLUE) and Focus Assessed Transthoracic Echocardiography Protocol (FATE) has good application value in the etiological diagnosis of perioperative hypoxemia. The author combined BLUE protocol and FATE protocol to diagnose perioperative hypoxemia.

DIAGNOSTIC ACCURACY OF POINT-OF-CARE ULTRASOUND FOR EVALUATION OF DIASTOLIC DYSFUNCTION AND A PROPOSED ALGORITHM FOR BEDSIDE ASSESSMENT

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The purpose of this study was to assess agreement between point-of-care ultrasound (POCUS) and formal echocardiography for evaluation of diastolic dysfunction and left atrial pressure via measurement of E/A, E/e’ and e’, and to propose a pragmatic bedside assessment algorithm for the practicing critical care physician evaluating patients for the presence of heart failure with preserved ejection fraction (HFpEF). METHODS: This study was conducted at a single-center tertiary care center with a robust POCUS education program. Fifty POCUS exams were performed by a single internal medicine physician using a typical POCUS ultrasound system (SonoSite EDGE with a P21, 1-5mHz phased-array transducer) following each patient’s echocardiogram. The POCUS examiner, blinded to the echocardiogram, measured mitral inflow E and A via pulsed wave Doppler, and e’ of the septal mitral annulus via pulsed wave tissue Doppler. Bland-Altman plots were created to analyze the agreement between the quantitative measurements obtained by echocardiogram and POCUS. RESULTS: The mean difference between echocardiogram and POCUS for E/A, E/e’ and e’ were 0.11 (1.29 vs. 1.18), 2.02 (12.55 vs. 10.54), and -0.95 (8.08 vs. 9.03) cm/s respectively, with the 95% limits of agreement -0.07 - 0.31, 0.59 - 3.44, and -1.89 - -0.01 cm/s respectively. Given the mean and standard values of E/A, E/e’ and e’, the magnitude of disagreement between the each set of measurements was considered clinically insignificant. Notably, patient BMI, presence of COPD, technical difficulty classification of echocardiogram, nor the magnitude of the measurements for E, A, or e’ significantly impacted agreement. Median time between echocardiogram and POCUS was 80 min (range 28-350). CONCLUSIONS: This study suggests that POCUS can be used in hospitalized patients to reliably measure key Doppler indices used in the diagnosis of HFpEF. We propose a POCUS assessment algorithm for the rapid evaluation of diastolic dysfunction adapted from the American Society of Echocardiography algorithm. Limitations of bedside assessment of diastolic dysfunction are also described. CLINICAL IMPLICATIONS: As HFpEF overtakes heart failure with reduced ejection fraction (HFrEF) as the most predominant form of heart failure, the ability to accurately diagnosis diastolic dysfunction and elevated left atrial pressure at the bedside with POCUS becomes just as important as estimating systolic cardiac function. Further, in light of the COVID-19 pandemic, there is newly appreciated utility for the development of a practical bedside assessment of diastolic dysfunction which could help to minimize personnel exposure and preserve resources in similar circumstances. DISCLOSURES: No relevant relationships by Joshua Overgaard, source=Web Response No relevant relationships by Kirsten Shaw, source=Web Response No relevant relationships by David Tierney, source=Web Response

Development of a novel pediatric point-of-care ultrasound question bank using a modified Delphi process.

Measuring pediatric emergency medicine (PEM) fellow competency in point-of-care ultrasound (POCUS) is important for ensuring adequate training and performance. Assessment may include direct observation, image review, quality assessment, and written examination. The purpose of this study was to develop a pediatric POCUS question bank that could subsequently be used as a POCUS assessment for graduating PEM fellows. We organized a 10-person question writing group (QWG). Eight hold expertise in POCUS and twohold expertise in medical education. Members of the QWG created questions within four domains: interpretation/diagnosis (50% of questions), anatomy (30%), physics (10%), and pitfalls (10%). POCUS faculty ascertained content validity and the medical education faculty revised questions for syntax and readability. In 2016, we recruited 31pediatric POCUS experts. The majority were members of the P2Network, an international group of experts and leaders in PEM POCUS, to participate in three iterative rounds of a modified Delphi process to review, revise, and establish consensus on the question bank. Thirty-one pediatric POCUS experts participated in the three rounds of the modified Delphi process and evaluated 437 questions developed by the expert panel. Forty-nine percent (n=216) of the questions were accepted in round 1, 30% (n=130) in round 2, and 11% (n=47) in the final round. The final question bank included 393 questions covering 17 pediatric POCUS applications. We developed a 393-question bank to aid in the assessment of PEM POCUS competency. Future work includes piloting the questions with PEM fellows to evaluate the response process and implementing the assessment tool to establish a minimum passing score.

The Ultrasound Competency Assessment Tool (UCAT): Development and Evaluation of a Novel Competency-based Assessment Tool for Point-of-care Ultrasound.

Point-of-care ultrasound (POCUS) has become an integral diagnostic and interventional tool. Barriers to POCUS training persist, and it continues to remain heterogeneous across training programs. Structured POCUS assessment tools exist, but remain limited in their feasibility, acceptability, reliability, and validity; none of these tools are entrustment-based. The objective of this study was to derive a simple, entrustment-based POCUS competency assessment tool and pilot it in an assessment setting. This study was composed of two phases. First, a three-step modified Delphi design surveyed 60 members of the Canadian Association of Emergency Physicians Emergency Ultrasound Committee (EUC) to derive the anchors for the tool. Subsequently, the derived ultrasound competency assessment tool (UCAT) was used to assess trainee (N=37) performance on a simulated FAST examination. The intraclass correlation (ICC) for inter-rater reliability and Cronbach's alpha for internal consistency were calculated. A statistical analysis was performed to compare the UCAT to other competency surrogates. The three-round Delphi had 22, 26, and 26 responses from the EUC members. Consensus was reached, and anchors for the domains of preparation, image acquisition, image optimization, and clinical integration achieved approval rates between 92 and 96%. The UCAT pilot revealed excellent inter-rater reliability (with ICC values of 0.69-0.89; p<0.01) and high internal consistency (α= 0.91). While UCAT scores were not impacted by level of training, they were significantly impacted by the number of previous POCUS studies completed. We developed and successfully piloted the UCAT, an entrustment-based bedside POCUS competency assessment tool suitable for rapid deployment. The findings from this study indicate early validity evidence for the use of the UCAT as an assessment of trainee POCUS competence on FAST. The UCAT should be trialed in different populations performing several POCUS study types.

Respiratory Variation in Carotid Artery Peak Systolic Velocity Is Unable to Predict Fluid Responsiveness in Spontaneously Breathing Critically Ill Patients When Assessed by Novice Physician Sonologists.

Respiratory variation in carotid artery peak systolic velocity (ΔVpeak) assessed by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means to predict fluid responsiveness. We aimed to evaluate the ability of carotid ΔVpeak as assessed by novice physician sonologists to predict fluid responsiveness. This study was conducted in 2 intensive care units. Spontaneously breathing, nonintubated patients with signs of volume depletion were included. Patients with atrial fibrillation/flutter, cardiogenic, obstructive or neurogenic shock, or those for whom further intravenous (IV) fluid administration would be harmful were excluded. Three novice physician sonologists were trained in POCUS assessment of carotid ΔVpeak. They assessed the carotid ΔVpeak in study participants prior to the administration of a 500 mL IV fluid bolus. Fluid responsiveness was defined as a ≥10% increase in cardiac index as measured using bioreactance. Eighty-six participants were enrolled, 50 (58.1%) were fluid responders. Carotid ΔVpeak performed poorly at predicting fluid responsiveness. Test characteristics for the optimum carotid ΔVpeak of 8.0% were: area under the receiver operating curve = 0.61 (95% CI: 0.48-0.73), sensitivity = 72.0% (95% CI: 58.3-82.56), specificity = 50.0% (95% CI: 34.5-65.5). Novice physician sonologists using POCUS are unable to predict fluid responsiveness using carotid ΔVpeak. Until further research identifies key limiting factors, clinicians should use caution directing IV fluid resuscitation using carotid ΔVpeak.

Early Point-of-Care Ultrasound Assessment for Medical Patients Reduces Time to Appropriate Treatment: A Pilot Randomized Controlled Trial

Numerous studies emphasize the diagnostic importance of point-of-care ultrasound (POCUS), but the level of evidence remains low as most data are gathered from observational studies. We conducted a pilot, randomized controlled trial to evaluate the effect of POCUS exam on medical patient's management and clinical outcomes. Patients presenting with chest pain or dyspnea were enrolled and randomly allocated to an early POCUS scan group and a control group. POCUS assessment, within 24 h of internal ward admission, was conducted only for the intervention group. The primary outcome was time to correct diagnosis. Secondary outcomes included time to appropriate treatment, POCUS-related rate of primary diagnosis alteration and new clinically relevant findings and time to hospital discharge. Sixty patients were enrolled. Thirty patients were randomly allocated to each study arm. The POCUS exam revealed clinically relevant findings among 79% of patients and led to alteration of the primary diagnosis among 28% of patients. Time to appropriate treatment was significantly shorter among patients in the POCUS group compared with the control group (median time of 5 h [95% confidence interval: 0.5–9] vs. 24 h [95% CI: 19–29] p = 0.014). The time needed to achieve correct diagnosis by the primary team was shorter in the POCUS group compared with the control group, yet it did not reach statistical significance (median time of 24 h [95% CI: 18–30] vs. 48 h [95% CI: 20–76], p = 0.12). These results indicate that POCUS assessment conducted early among patients with dyspnea or chest pain improves diagnostic accuracy and shortens significantly the time to appropriate treatment.

LO40: Services for emergency department patients experiencing early pregnancy complications: a survey of Ontario hospitals

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

210 Towards Reducing Operator Dependence in Ultrasound: Oriented 3D Volumetric Imaging of Second Trimester Fetuses and Reliability of Image Volume Interpretation by Expert and Novice Raters

Point-of-care (POC) obstetric ultrasound (US) is an essential tool in the emergency setting, but its clinical utility is limited by the inherent operator dependence of US. Performing a thorough and accurate US examination requires highly trained and experienced operators. We developed a low cost system enabling acquisition of oriented 3D image volumes using any existing 2DUS machine. We hypothesized that a novice sonographer could use the device to acquire image volumes of second trimester fetuses that could then be interpreted for assessment of basic parameters and reliable biometric measurements by both novice and expert raters. A student with minimal US experience (novice) swept the 2DUS transducer with paired research device across the region of interest to acquire image volumes of second trimester fetuses from 32 subjects. Volumes were reconstructed using a pixel-based algorithm. Acquisition and reconstruction times were automatically recorded. Image volumes were viewed in 3DSlicer; the percentage of interpretable volumes was recorded. An expert made blinded, timed assessments of placental location (PL), fetal presentation (FP), and amniotic fluid volume (AFV) for each subject. Both novice and expert raters blindly, independently measured BPD, humerus, and femur; corresponding gestational age (GA) estimates were calculated. Inter-rater reliability of biometric measurements and associated GA between each rater and clinical US reports and between raters were assessed by intraclass correlation coefficient (ICC). Mean inter-rater differences were analyzed by 1-way ANOVA. Mean (SD) age, GA, and body mass index were 30.6 years (±6.2), 18.9 weeks (±2.6), and 26.0 (±4.4). Volume acquisition and reconstruction required mean 30.4s (±5.7) and 70.0s (±24.0). PL, FP, and AFV could be evaluated from volumes for all subjects. At least 1 structural measurement was possible for 31 subjects (97%). Mean time for expert assessment of PL, FP, and AFV was 16s (± 0.0). Agreement for all measures between all rater pairs was excellent (ICCs greater than 0.95). ICCs between all rater pairs for each biometric measure and corresponding GA estimate demonstrated either good or excellent reliability. ICCs were highest for GA estimates by BPD between both raters and reported values (expert ICC: 0.97 CI95% 0.94-0.99; novice ICC: 0.97 CI95% 0.94-0.99). Mean inter-rater differences were not significant. Comprehensive image volumes of second trimester fetuses were rapidly acquired by a novice sonographer and reconstructed for interactive visualization. PL, FP, and AFV could be quickly assessed by an expert for all subjects. Measurements of BPD, femur, and humerus were made for the vast majority of subjects. Both the measurements and GA estimates were highly reliable between both novice and expert raters and clinical reports. This low cost system could reduce the operator dependence of US, thereby enhancing its utility in any clinical scenario in which POC US assessment is required. It could also facilitate task-shifting among health care personnel to increase the efficiency of triage and diagnostic evaluation.

Three-window ultrasonography confirmation of endotracheal tube placement

Background: Establishing a definitive airway is often an initial step in the management of critically ill patients in the emergency department (ED). Currently, there is no universally accepted gold standard for airway confirmation. Recent literature has shown that point-of-care ultrasound (POCUS) may be helpful in confirming the correct endotracheal tube (ETT) placement. Objective: The objective of this study is to evaluate the accuracy of a comprehensive three-window POCUS assessment to confirm correct ETT placement. Methods: This was a prospective, single-center, observational study using a convenience sample of patients in the ED and Medical Intensive Care Unit. After presumed successful ETT intubation, three sonographic windows were obtained, which included the trachea, bilateral lung sliding, and diaphragm movement. Results: We enrolled a total of 140 patients. There were no esophageal intubations. The three-window POCUS method correctly identified 132 of 137 ETTs placed in the trachea with 96.4% sensitivity (95% confidence interval [CI] 91.7%–98.8%) and 33.3% specificity (95% CI 0.8%–90.6%). Only one of the three mainstem intubations was identified using POCUS. Ultrasound assessment was completed on average 25 min quicker than the usual confirmatory plain film radiography (95% CI 6.2–43.9 min, P = 0.005). Conclusions: The three-window POCUS assessment is a rapid and potentially reliable method to identify ETT intubation, but may not be reliable at confirming mainstem intubation.

Case Report: Type 1 aortic dissection presenting as acute pericarditis: the roles of POCUS and transthoracic echocardiography

Clinical Presentation: A 59 year old male presented with a 1 day history of non-exertional chest pain that was pleuritic in nature and aggravated by lying flat. His chest pain symptoms were preceded by a one week history of “flu-like” symptoms. Physical exam demonstrated a blood pressure of 114/55 mmHg, heart rate of 75 bpm, and a normal oxygen saturation on room air. Cardiac examination revealed a biphasic pericardial rub vs. to-and-fro murmur. EKG demonstrated diffused ST-elevation and PR depression consistent with acute pericarditis. Laboratory findings revealed a normal WBC of 11.2×109/L and hsTnT of 78 ng/L. Imaging Findings: A point of care ultrasound (POCUS) assessment demonstrated mild aortic insufficiency with a dilated ascending aorta with no pericardial effusion or wall motion abnormalities. An expedited transthoracic echocardiography (TTE) confirmed a bicuspid aortic valve with moderate aortic insufficiency. The aortic root and ascending aorta were dilated at 50 and 52 mm, respectively. There was evidence of an aortic dissection flap prolapsing across the left ventricular outflow tract. A dissection flap was also visualized within the abdominal aorta consistent with a Type 1 aortic dissection. Computed tomography of the aorta confirmed the Type 1 aortic dissection and the patient underwent an urgent valve-sparing aortic root replacement procedure. Discussion Points: Despite a typical clinical presentation for acute pericarditis, any unexpected physical exam or laboratory findings should lead to a POCUS assessment. This case demonstrates a rare presentation of aortic dissection which could have been easily missed without a POCUS assessment. Here we propose an algorithm for a POCUS examination in setting of pleuritic chest pain consistent with pericarditis.

Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes.

Distal forearm fractures are the most common fracture type in children. Point-of-care-ultrasound (POCUS) is increasingly being used, and preliminary studies suggest that it offers an accurate approach to diagnosis. However, outcomes such as pain, satisfaction, and procedure duration have not been explored but may be salient to the widespread acceptance of this technology by caregivers and children. Our objectives were to examine the test performance characteristics of POCUS for nonangulated distal forearm injuries in children and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and procedure duration. We conducted a cross-sectional study involving children aged 4-17 years with a suspected nonangulated distal forearm fracture. Participants underwent both x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS and x-ray, the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale-Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration. POCUS was performed in 169 children of whom 76 were diagnosed with a fracture including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7% (95% confidence interval [CI] = 89.7-99.8) and specificity was 93.5% (95% CI = 88.6-98.5). POCUS was associated with a significantly lower median (interquartile range [IQR]) pain score compared to x-ray: 1 (0-2) versus 2 (1-3), respectively (median difference = 0.5; 95% CI = 0.5-1; p < 0.001) and no significant difference in median (IQR) caregiver satisfaction score: 5 (0) versus 5 (4-5), respectively (median difference = 0, 95% CI = 0, p = 1.0). POCUS was associated with a significantly lower median (IQR) procedure duration versus x-ray: 1.5 (0.8-2.2) minutes versus 27 (15-58) minutes, respectively (median difference = 34.1, 95% CI = 26.8-41.5, p < 0.001). Our findings suggest that POCUS assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction.