Point-of-care Ultrasound Findings Research Articles

Point of Care Ultrasound for Diagnosis and Management in Heart Failure: A Targeted Literature Review.

Cardiac point of care ultrasound (POCUS) has shown increasing utility as a tool for diagnosing and managing heart failure (HF). Within cardiology, intravascular volume assessment leveraging visualization of the inferior vena cava (IVC) is a central aspect of care, as IVC size correlates with central venous pressure. This targeted literature review aimed to examine the existing literature assessing the use of POCUS in diagnosis and management of HF patients utilizing POCUS-based IVC measurement either alone or in combination with secondary methods. A targeted PubMed and Ovid database search up until August 28, 2023 using a keyword search was completed. Studies that did not include IVC assessment with POCUS in HF were excluded. The initial search using both PubMed and Ovid resulted in 370 journal publications. After exclusion criteria were used 15 studies were included in the review.Studies were grouped into three categories: 1) how well POCUS was able to identify HF, 2) whether POCUS-based findings correlated with other measures evaluating HF and was able to predict the effect of diuretic administration, and 3) whether POCUS-based findings served as a good prognostic indicator. The 5 studies that evaluated HF identification with POCUS found that both diagnostic sensitivity and specificity may reach 90%-100% when IVC measurement was coupled with a lung ultrasound assessing the presence of B-lines or pleural effusion. Five studies assessing POCUS findings correlating with other HF measures and diuretic effect found that IVC diameter changed significantly with diuretic administration (p<0.05). All 6 studies assessing POCUS as a predictor of long-term mortality or hospital readmission found measures that achieved statistical significance with p<0.05. Including POCUS as standard-of-care - both as a diagnostic tool in the emergency department and a management tool in in-patient and out-patient facilities - may improve the treatment of HF.

A 12-year Retrospective Cohort Study of Point-of-care Ultrasound and Aortic Dissection Risk Score in Type A Aortic Dissection

BackgroundAortic dissection (AD) is a vascular emergency with time-dependent mortality. Point-of-care ultrasound (POCUS) and aortic dissection risk score (ADRS) have been proposed as diagnostic tools to risk stratify patients and reduce time to diagnosis. ObjectiveWe evaluate POCUS findings and ADRS in a retrospective cohort of patients with known type A AD. The objective of this study is to describe the prevalence of POCUS findings and ADRS in this population. MethodsThis is a retrospective cohort study of patients with acute type A AD as confirmed on CT scan over a 12-year period from 2008-2020, with a subgroup analysis of patients who received POCUS in the emergency department. ADRS was calculated and POCUS findings were reviewed. Descriptive statistics were used to describe the distribution of POCUS findings. Results91 patients met inclusion criteria. POCUS was performed in 41 but only 35 had images of adequate quality for inclusion. Of the POCUS images available, 30/35 (86%) patients had a POCUS finding consistent with dissection and 5/35 (14%) had no findings on POCUS. 12% (11/91) of patients had ADRS=0. Two patients with ADRS=0 received POCUS, and 1 patient had no findings on POCUS. ConclusionAlthough POCUS provides rapid information in the diagnosis of type A AD, 14% of patients with images available for review had no findings on POCUS. Of the whole cohort, 12% had an ADRS=0. Further studies are needed to identify an optimal diagnostic pathway for this catastrophic disease.

Utilizing Point-Of-Care Ultrasound (POCUS) for Diagnosis in a Resource-Limited Setting: A Case Report of Pulmonary Embolism

Introduction: Acute pulmonary embolism (PE) is a common cause of cardiovascular-related deaths and poses diagnostic challenges due to its variable and non-specific symptoms. Computed tomography pulmonary angiography (CTPA) is the gold standard imaging method for PE diagnosis, but its availability is limited in resource-constrained settings. Point-of-care ultrasound (POCUS) has emerged as a valuable tool for emergency physicians, aiding accurate diagnoses, procedural guidance, and resuscitation efforts. Case Presentation: This case report presents a 76-year-old woman with non-specific symptoms diagnosed with PE using POCUS in the Emergency Department of the Korle Bu Teaching Hospital. The POCUS findings included an enlarged right ventricle with a flattened septum (D sign), poor cardiac contractility, thrombi in the right ventricle and a plethoric Inferior Vena Cava (IVC). Prompt diagnosis facilitated timely management, leading to improved patient outcomes. Conclusion: POCUS has proven to be indispensable in resource-constrained settings where confirmatory diagnostics are limited. Incorporating POCUS training into emergency medicine residency programs and establishing emergency ultrasound fellowships in under-resourced regions like Africa can enhance its utilization and empower clinicians in such environments. Equipping emergency room clinicians with POCUS skills enables timely diagnosis, early interventions, shorter Emergency Department stays, and improved patient outcomes. This approach can contribute to building an African faculty proficient in emergency ultrasound, facilitating the education and training of more clinicians in POCUS, and ultimately enhancing healthcare outcomes in resource-limited environments.

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.

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.

Renal point-of-care ultrasound performed by ED staff with limited training and 30-day outcomes in patients with renal colic.

Emergency Department (ED) renal point-of-care ultrasound (PoCUS) in renal colic by accredited specialists has good prognostic value. This may not be generalizable to under-resourced EDs. We investigated PoCUS in renal colic in our ED with lesser training. We performed a single-centre health records review of adult ED patients with renal colic and PoCUS. Patients were managed by a non-ED specialist/resident doctor with no POCUS accreditation in consultation with an attending. These doctors attended a 3.5-h training session conducted by accredited attendings to examine hydronephrosis. They needed to verify their PoCUS findings with an attending during the first two weeks of their six-month posting before performing it independently. The primary outcome was 30-day urological procedures in hydronephrotic vs. non-hydronephrotic groups. Secondary outcomes were the distribution of primary outcome with grades of hydronephrosis, 30-day ED nephrolithiasis-related reattendances in hydronephrotic vs. non-hydronephrotic groups and its distribution with grades of hydronephrosis. We compared outcomes using Fisher's exact test. We also reported crude odds ratio (COR) and 95% CI of primary outcome between hydronephrotic vs. non-hydronephrotic groups. p values ≤ 0.05 were significant. We recruited 651 patients; 160 (24.6%) without and 491 (75.4%) with hydronephrosis. Rates of grades of hydronephrosis were: mild (76.6%), moderate (13.8%), severe (1.2%) and undifferentiated (8.4%). There was a difference in 30-day urological procedures (rates [95% CI]) in hydronephrotic vs. non-hydronephrotic groups, 11.2 [8.7-14.0]% vs. 2.5 [1.0-6.3]%; p < 0.001; COR (95% CI) 4.9 (1.8-13.8); p = 0.002. Increasing 30-day urological procedural rates were associated with increasing grade of hydronephrosis [no: 2.5%, mild: 7.7%, moderate: 23.5%, severe: 67.0% and undifferentiated: 14.6%; p < 0.001]. No differences occurred in other secondary outcomes. Renal PoCUS could be performed by non-ED specialist/resident doctors to identify patients without hydronephrosis who rarely required urological intervention. Hydronephrotic patients could benefit from further risk stratification.

Invasive Fungus Balls Diagnosed by Point-of-Care Ultrasound in the Emergency Department

BackgroundGenitourinary tract fungus balls are a rare complication of urinary tract infections (UTI). They arise from dense aggregations of hyphae that combine with surrounding urothelial cells and debris. Symptoms can progress to urosepsis and systemic dissemination. Unfortunately, fungus balls may remain unrecognized. Even with computed tomography (CT) and magnetic resonance imaging, fungus balls can be mistaken for malignancies, urinary calculi, or blood clots. Case ReportA 54-year-old man with past medical history of type 2 diabetes mellitus presented to the Emergency Department (ED) reporting urinary retention for one week. He had undergone Foley catheter insertion three separate times for this symptom over the past five weeks. The emergency physicians expected that point-of-care ultrasound (POCUS) would show a distended, anechoic bladder. Instead, there were multiple discrete, gravitationally-dependent, circular echogenic masses without posterior acoustic shadowing, floating freely within a mosaic-like background of mixed echogenicity urine. These findings, together with the CT scan subsequently ordered, raised concern for fungus balls. Instead of being discharged with antibiotics for UTI, the patient was admitted for antifungal coverage, with contingency plans for bladder irrigation and antifungal instillation as needed. Why Should an Emergency Physician be Aware of This?This is the first known case report in which emergency physicians used POCUS to diagnose invasive fungus balls in the ED. POCUS findings led to further CT imaging and specialist consultation that otherwise would not have occurred. Rather than discharge with antibiotics, goal-directed management and appropriate disposition mitigated the risk of systemic decompensation in an immunocompromised patient.

Point-of-Care Ultrasound for Tuberculosis in Young Children with Severe Acute Malnutrition.

Point-of-care ultrasound (POCUS) to diagnose tuberculosis (TB) was assessed in 131 children under 5 years old hospitalized with severe acute malnutrition. Of these, 23% had confirmed or unconfirmed TB and 5% were HIV-infected. There were no POCUS findings associated with TB diagnosis. POCUS visualization quality was satisfactory for 65% and examination acceptability was "good" for 52%.

Impact of Point-of-Care Ultrasound on Prehospital Decision Making by HEMS Physicians in Critically Ill and Injured Patients: A Prospective Cohort Study.

Several studies have shown the additional benefit of point-of-care ultrasound (POCUS) by prehospital Emergency Medical Services (EMS). Since organization of EMS may vary significantly across countries, the value of POCUS likely depends on the prehospital system in which it is used. In order to be able to optimally implement POCUS and develop a tailored training curriculum, it is important to know how often POCUS is currently used, for which indications it is used, and how it affects decision making. The aims of this study were: (1) to determine the percentage of patients in whom POCUS was used by Dutch Helicopter Emergency Medical Services (HEMS) crews; (2) to determine how often POCUS findings led to changes in on-scene management; and (3) what these changes were. Patients who received prehospital care from December 1, 2020 through March 31, 2021 by a single HEMS crew were included in this prospective cohort study. Clinical data and specific data on POCUS examination, findings, and therapeutic consequences were collected and analyzed. During the study period, on-scene HEMS care was provided to 612 patients, of which 211 (34.5%) patients underwent POCUS. Of these, 209 (34.2%) patients with a median age of 45 years were included. There were 131 (62.7%) trauma patients, and 70 (33.7%) of the included patients underwent cardiopulmonary resuscitation (CPR). The median reported time of POCUS examination was three (P25-P75 2-5) minutes. Median prolongation of on-scene time was zero (P25-P75 0-1) minutes. In 85 (40.7%) patients, POCUS examination had therapeutic consequence: POCUS was found to impact treatment decisions in 34 (26.0%) trauma patients and 51 (65.4%) non-trauma patients. In patients with cardiac arrest, POCUS was most often used to aid decision making with regard to terminating or continuing resuscitation (28 patients; 13.4%). During the study period, POCUS examination was used in 34.5% of all prehospital HEMS patients and had a therapeutic consequence in 40.7% of patients. In trauma patients, POCUS seems to be most effective for patient triage and evaluation of treatment effectiveness. Moreover, POCUS can be of significant value in patients undergoing CPR. A tailored HEMS POCUS training curriculum should include ultrasound techniques for trauma and cardiac arrest.

Diagnostic Performance of Point of Care Ultrasound Compared to Chest X-Ray in Patients with Hypoxia at a Teaching Hospital Emergency Department in Uganda

Hypoxia is a common presentation in the Emergency Department (ED) worldwide. It affects 9-12% of hospitalized adults in Sub-Saharan Africa. Timely diagnosis of the multiple causes such as pneumonia, heart failure among others is challenging. Chest X-Ray (CXR), one of the most utilized imaging modalities has many limitations, and the gold standard (Computed Tomography scan) is inaccessible. Point of care ultrasound (PoCUS) is more available and increasingly being used, however little is known of its performance in resource limited EDs. The study aimed to assess the diagnostic performance of PoCUS compared with CXR in identifying the causes of hypoxia in the medical ED. 49 adults presenting with hypoxia (SP02 ≤ 88%) in the medical ED were evaluated. Ultrasound of the lungs and heart (PoCUS) was done, then CXR obtained. Lung ultrasound (LUS) was compared with CXR (first reference standard). Chest X-Ray and PoCUS were each compared to the physician diagnosis (second reference standard) to determine agreement using an acceptable disagreement cut-off of 15%. 31% more abnormalities were identified by LUS than CXR. Lung ultrasound findings agreed with CXR in 86% of the participants with moderate reliability (ĸ=0.75). There was no significant difference between the actual findings of the two tests (X2= 2, p 0.1). Using the second reference, 82% of the CXRs were similar with weak reliability (ĸ=0.5) compared to 98% of PoCUS findings with strong reliability (ĸ=0.9). Compared to PoCUS, CXRs significantly differed from the physician diagnosis (X2= 0.85, p 0.38 vs X2= 8.5, p 0.004 respectively). Overall, PoCUS was not inferior to CXR when compared to final physician diagnosis in identifying causes of hypoxia, and LUS and CXR had comparable performance. Significantly more abnormalities were identified on PoCUS and it demonstrated better agreement and strong reliability with the physician diagnosis than CXR. We recommend PoCUS use in patients with hypoxia attending resource limited in- and pre-hospital settings.

Point of care ultrasound findings in critically ill SARS-COV2 patients in an HIV endemic, resourced constrained setting

ObjectivesTo describe the incidence of venous thromboembolism (VTE) in mechanically ventilated COVID-19 patients in an HIV endemic, resourced constrained setting. To describe the incidence of VTE in relation to HIV status and anticoagulant therapy, and to evaluate VTE-associated cardio-respiratory changes. To establish the contribution of HIV, anticoagulation therapy and other risk factors to mortality. DesignProspective descriptive study. SettingSingle-center tertiary teaching hospital. ParticipantsOne hundred and one consecutively admitted critically ill adult patients with COVID-19 acute respiratory distress syndrome. InterventionsPoint of care ultrasound (POCUS) assessment of the lower limbs and the cardio-respiratory system was performed on intensive care unit (ICU) admission and repeated if clinically indicated. Measurements and main resultsDVT was diagnosed by POCUS, whilst pulmonary embolism was diagnosed using a combination of clinical criteria and POCUS (echocardiography and chest wall ultrasound). VTE was diagnosed in 16/101 (16%) patients, despite 14/16 (88%) receiving prior therapeutic dosage of low molecular weight heparin. Clinically significant PE was diagnosed in 5/16 (31%) with 11/16 (69%) having DVT only. The majority of VTE patients, 12/16 (75%), demised 16/101 (16%) patients had HIV co-infection, and 4/16 (25%) with HIV had VTE. Valvular abnormalities were the most common cardiac abnormality with marked tricuspid regurgitation detected in 51/101 (51%). The absence of right atrial enlargement had a 93% negative predictive value for the absence of VTE. Univariate analysis did not demonstrate statistically significant individual risk factors for mortality. ConclusionsMechanically ventilated COVID- 19 patients at ICU admission had a low incidence of VTE (16%). Therapeutic dose anticoagulation did not reduce mortality compared to prophylactic dosage. In contrast to findings from other studies, no individual risk factor contributed significantly to mortality, likely due to small sample size. POCUS is an ideal screening tool to aid in the assessment of critically ill patients.

N‐terminal brain natriuretic peptide, cardiactroponin‐I, and point‐of‐care ultrasound in dogs with cardiac and noncardiac causes of nonhemorrhagic ascites

Nonhemorrhagic ascites (NHA) can be caused by cardiac diseases (cNHA) and noncardiac diseases (ncNHA). N-terminal brain natriuretic peptide (NT-proBNP), cardiac troponin-I (cTnI), and point-of-care ultrasound (POCUS) may differentiate between cNHA and ncNHA. We compared NT-proBNP and cTnI concentrations as well as POCUS findings in dogs presented with cNHA and ncNHA. Dogs (n = 60) were enrolled based on identification of NHA with an effusion packed cell volume < 10%. Blood samples were collected and POCUS was performed on all dogs. Dogs were diagnosed with cNHA (n = 28) or ncNHA (n = 32) based on echocardiography. The cNHA group was subdivided into cardiac non-pericardial disease (n = 17) and pericardial disease (n = 11). The NT-proBNP concentration (median; range pmol/L) was significantly higher in the cNHA group (4510; 250-10 000) compared to the ncNHA group (739.5; 250-10 000; P = .01), with a sensitivity of 53.8% and specificity of 85.7% using a cut-off of 4092 pmol/L. The NT-proBNP concentrations were significantly higher in the cardiac non-pericardial disease group (8339; 282-10 000) compared with the pericardial disease group (692.5; 250-4928; P = .002). A significant difference in cTnI concentration (median; range ng/L) between the cNHA group (300; 23-112 612) and ncNHA group (181; 17-37 549) was not detected (P = .41). A significantly higher number of dogs had hepatic venous and caudal vena cava distension in the cNHA group compared to the ncNHA group, respectively (18/28 vs 3/29, P < .0001 and 13/27 vs 2/29, P < .001). Gall bladder wall edema was not significantly different between groups (4/28 vs 3/29, P = .74). NT-proBNP concentration and POCUS help distinguish between cNHA and ncNHA.

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.

Utilization of point-of-care ultrasound among graduates of a 4-year longitudinal medical school ultrasound curriculum.

In 2011, School of Medicine, University of California, Irvine was among the first schools to implement a 4-year ultrasound curriculum. We aimed to find the point-of-care ultrasound (POCUS) utilization pattern among University of California, Irvine alumni. We surveyed University of California, Irvine alumni from the class of 2011 and beyond. Survey questions included POCUS reliance, frequency of use, and comfort with image acquisition and interpretation compared with peers. The primary outcomes were self-reported comfort and reliance on POCUS. We received 93 responses from 624 surveyed alumni (response rate, 14.9%), of which 87 were analyzed. Although 46 respondents (52.9%) reported more reliance on POCUS, three (3.4%) relied on it less than their peers. At the same time, 72 (82.7%) and 67 (77.0%) felt more comfortable than their colleagues in obtaining and interpreting POCUS, respectively. No respondents felt less comfortable obtaining or interpreting POCUS than their peers. The frequency of POCUS use correlated directly with the frequency with which POCUS changed the responder's case management (rho, 0.860; P<0.001). POCUS reliance also correlated with respondents' comfort level in obtaining (rho, 0.321; P<0.001) and interpreting (rho, 0.378; P<0.001) POCUS results. University of California, Irvine graduates had higher reliance on POCUS than peers in their respective specialties. Their POCUS findings frequently changed their case management.

Hip effusions or iliopsoas hematomas on ultrasound in identifying hip fractures in the emergency department

ObjectiveWe evaluated the sensitivity, specificity, predictive values, and likelihood ratios of hip effusion and/or iliopsoas hematoma on point-of-care ultrasound (POCUS) performed by ultrasound fellows and fellowship trained emergency providers to identify hip fractures in emergency department (ED) patients with a high suspicion of hip fracture. MethodsThis was a prospective observational study of a convenience sample of patients with high suspicion of hip fracture at two academic EDs between 2018 and 2021. Patients with negative x-rays who did not receive further imaging with magnetic resonance imaging (MRI) or computed tomography (CT) were excluded. Sonographers were blinded to clinical data and ED imaging results. At the primary site, 8 ultrasound fellows and 4 emergency ultrasound fellowship-trained emergency providers performed the ultrasonographic examinations. At the secondary site, 2 ultrasound fellows, 4 emergency ultrasound-fellowship trained physicians, and 1 sports medicine fellowship-trained emergency provider performed the ultrasonographic examinations. A positive ultrasound was defined as either the presence of a hip effusion or iliopsoas hematoma on the affected extremity. The primary outcome measures were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of POCUS findings for identification of a hip fracture compared with a ranked composite reference standard consisting of x-ray, CT, or magnetic resonance imaging (MRI); the highest-level test performed for each patient was used for comparison. ResultsAmong 213 patients analyzed, all 213 received an x-ray, 116 received a CT scan, and 14 received an MRI; 113/213 x-rays (53.1%), 35/116 CT scans (30.2%), and 7/14 MRIs (50.0%) were positive for a hip fracture. A total of 123 patients were diagnosed with a hip fracture (57.7%). There were 13 false negative x-ray results. Overall, compared with the reference standard of x-ray, CT, or MRI, POCUS had a sensitivity of 97% (95% CI: 94%, 100%), specificity of 70% (95% CI: 61%, 79%), PPV of 82% (95% CI: 75%, 88%), and NPV of 94% (95% CI: 88%, 100%) in the identification of hip fractures; with a positive likelihood ratio of 3.22 (95% CI: 2.35, 4.43) and negative likelihood ratio of 0.05 (95% CI: 0.02, 0.12). ConclusionIn a convenience sample of ED patients with high clinical suspicion for hip fracture, the presence of a hip effusion and/or iliopsoas hematoma on POCUS performed by expert emergency ultrasonographers showed high sensitivity in diagnosing patients with a hip fracture.

Point-of-Care Ultrasound for the Diagnosis of Pediatric Testicular Torsion: A Retrospective Case Series Analysis.

Acute testicular torsion is a surgical emergency that warrants prompt treatment. The diagnosis is typically confirmed by ultrasonography interpreted by a radiologist (RADUS); however, in this study, we describe the clinical course of 23 patients for whom point-of-care ultrasound (POCUS) was performed by pediatric emergency medicine physicians during the initial assessment for testicular torsion in the pediatric emergency department (PED). A retrospective case series analysis of patients aged 0 to 18 years who were diagnosed with acute testicular torsion after undergoing scrotal POCUS through our PED. Between June 2015 and December 2020, 155 boys received an International Classification of Diseases-9 code of Torsion of Testis after presenting to our PED. Seventy-three patients were imaged preoperatively, of which 50 (68.5%) were diagnosed via RADUS alone. Twenty-three patients (31.5%) underwent POCUS (median age 14.1 years [interquartile range {IQR}: 11.4-15.9 years]), of which 14 (60.9%) were imaged by POCUS alone, whereas the remaining 9 patients (39.1%) underwent POCUS before RADUS. Thirteen of the 23 patients (56.5%) who underwent POCUS had intraoperative findings consistent with acute testicular torsion, whereas another 3 patients (13.0%) required manual detorsion in the PED before orchiopexy. Six patients required orchiectomy. All patients for which POCUS findings were suggestive of acute testicular torsion were correctly classified.The median length of stay from time to admission to orchiopexy for those who received RADUS only versus POCUS only was 184 minutes (IQR: 136-255), and 121 minutes (IQR: 80-202), respectively ( P = 0.036). Among the patients who experienced POCUS, the median length of stay for those who underwent RADUS in addition to POCUS compared with those who underwent POCUS alone was 202 minutes (IQR: 136-338.4) ( P = 0.031). Point-of-care ultrasound performed by pediatric emergency medicine physicians can be used to expedite surgical management and streamline the management of pediatric patients suspected of acute testicular torsion.

Point-of-Care Ultrasound and Right Ventricular Strain: Utility in the Diagnosis of Pulmonary Embolism

Pulmonary emboli are associated with high morbidity and mortality, prompting early diagnostic and therapeutic considerations. Utilization of rapid point-of-care ultrasound (POCUS) to assess for signs of pulmonary emboli can provide valuable information to support immediate treatment. We present a case of suspected pulmonary embolism in the setting of pharmacological prophylaxis for venous thromboembolism with identification of right heart strain on bedside POCUS exam. Early treatment with anticoagulation was initiated considering the clinical presentation and POCUS findings. CT angiogram of the chest revealed bilateral pulmonary emboli, confirming our suspicion. Utilizing POCUS in a case of suspected pulmonary emboli can aid in clinical decision making.

Aortic Dissection Presenting as Shortness of Breath from Diffuse Alveolar Hemorrhage

BackgroundAortic dissection is a rare but well-known life-threatening disease that classically presents with tearing chest pain radiating to the back yet can have deceiving clinical presentations. Case ReportA 54-year-old man with a history of hypertension presented to the emergency department with mild shortness of breath without chest pain. Point-of-care ultrasound (POCUS) detected diffuse B-lines, a dilated aortic root, aortic regurgitation, and pericardial effusion. A computed tomography angiogram confirmed a Stanford type A aortic dissection with diffuse alveolar hemorrhage (DAH), a rare complication of type A aortic dissection involving the posterior aortic wall with extension into the main pulmonary artery. Why Should an Emergency Physician Be Aware of This?Acute aortic dissection can present with a wide range of clinical manifestations with a high mortality rate for patients with an untimely diagnosis. Although an intimal flap within the aortic lumen is the characteristic finding on ultrasound, additional POCUS findings of a pericardial effusion, aortic regurgitation, and a dilated aortic root may be seen with proximal dissections. Diffuse B-lines on thoracic POCUS, although commonly associated with pulmonary edema in decompensated heart failure, can be seen in patients with DAH which has a multitude of etiologies, including aortic dissection.

Point-of-Care Gastric Ultrasound Confirms the Inaccuracy of Gastric Residual Volume Measurement by Aspiration in Critically Ill Children: GastriPed Study.

IntroductionNo consensus exists on how to define enteral nutrition tolerance in critically ill children, and the relevance of gastric residual volume (GRV) is currently debated. The use of point-of-care ultrasound (POCUS) is increasing among pediatric intensivists, and gastric POCUS may offer a new bedside tool to assess feeding tolerance and pre-procedural status of the stomach content.Materials and MethodsA prospective observational study was conducted in a tertiary pediatric intensive care unit. Children on mechanical ventilation and enteral nutrition were included. Gastric POCUS was performed to assess gastric contents (empty, full of liquids or solids), and gastric volume was calculated as per the Spencer formula. Then, GRV was aspirated and measured. The second set of gastric POCUS measurements was performed, similarly to the first one performed prior to GRV measurement. The ability of GRV measurement to empty the stomach was compared to POCUS findings. Both GRV and POCUS gastric volumes were compared with any clinical signs of enteral feeding intolerance (vomiting).ResultsData from 64 children were analyzed. Gastric volumes were decreased between the POCUS measurements performed pre- and post-GRV aspiration [full stomach, n = 59 (92.2%) decreased to n = 46 (71.9%), p =0.001; gastric volume: 3.18 (2.40–4.60) ml/kg decreased to 2.65 (1.57–3.57), p < 0.001]. However, the stomach was not empty after GRV aspiration in 46/64 (71.9%) of the children. There was no association between signs of enteral feeding intolerance and the GRV obtained, nor with gastric volume measured with POCUS.DiscussionGastric residual volume aspiration failed to empty the stomach and appeared unreliable as a measure of gastric emptiness. Gastric POCUS needs further evaluation to confirm its role.

Utilization of point-of-care ultrasound and rotational thromboelastometry (ROTEM) in the diagnosis and management of amniotic fluid embolism presenting as post-partum hemorrhage and cardiac arrest

AbstractObjectivesTo describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE).Case presentationA 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits.ConclusionsIn the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.