Point-of-care Ultrasound Findings Research Articles

Development of a nomogram to predict small bowel obstruction using point-of-care ultrasound in the emergency department

ObjectiveEarly diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis. MethodsUsing data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves. ResultsThe derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03–1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62–25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83–42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44–88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis. ConclusionA unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.

Emergency bedside ultrasound: benefits as well as caution - part 1. General.

The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed. Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited. The list of indications for POCUS nonetheless is increasing as practitioners acknowledge clinical benefits, and technological advancement improves diagnostic accuracy and efficiency of use. We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario.

377 Developing a Nomogram to Enhance Point-of-Care Ultrasound Utility in Predicting Small Bowel Obstruction Diagnosis and Outcome

Predicting the diagnosis and a need for surgical intervention in patients with small bowel obstruction (SBO) can assist with emergency physicians’ decisions in selecting appropriate management strategy in the ED. We developed and validated a unique nomogram for the prediction of SBO diagnosis based on clinical features and point-of-care ultrasound (POCUS) findings. We used data from a prospective cohort of patients in a single-institution database that consisted of 125 patients with suspected SBO who underwent POCUS evaluation in the ED of a tertiary academic center. Patients’ demographic and clinical data were collected, including age, sex, history of SBO, comorbidities, prior abdominal surgery, and clinician’s pre-test probability of SBO was surveyed prior to POCUS or CT scan results. Data from this cohort were analyzed to develop a nomogram integrating age, sex, comorbidities, prior abdominal surgery, physician’s pre-test probability, and POCUS findings to determine post-test risk of SBO. The associations of relevant clinical and demographical variables and POCUS findings with SBO diagnosis were assessed using Cox proportional hazards regression models. The discriminative ability of the nomogram was tested using C statistics, calibration plots, and Kaplan-Meier curves. The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO, and (10% [12/125]) underwent a surgical intervention. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: dilated loop of small bowel of at least 2.5 cm (hazard ratio [HR], 0.10; 95% CI, 0.04-0.16; P < .001), positive inter-luminal fluid (HR, 2.10; 95% CI, 0.96-3.24; P < .001), clinician’s high pretest probability (HR, 2.42; 95% CI, 0.36-4.48; P=0.021), and patient age (HR, 0.03; 95% CI, -0.00 to 0.07; P = 0.08). The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C statistic of 0.89 for the SBO diagnosis. A unique nomogram was developed to utilize the function of patient age, POCUS findings of small bowel > 2.5 cm in diameter, inter-luminal fluid, and pretest probability before POCUS to accurately predict the diagnosis of SBO. The nomogram was able to stratify patients into prognostic groups and performed well on internal validation. The nomogram should be prospectively validated in a novel cohort of patients at risk for SBO.

Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care.

Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations - focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) - in the rural context. This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators.

IntroductionThis third study in the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) series examined potential relationships between point-of-care ultrasound (PoCUS) use and the length of resuscitation, the frequency of interventions, and clinical outcomes during cardiac arrest.MethodsA health records review was completed for adult patients (>19 years, without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in cardiac arrest between 2010 and 2014. Patients were grouped based on PoCUS use and findings for cardiac activity. Data were analyzed for length of resuscitation, frequency of interventions, return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD).ResultsOf the 223 patients who met inclusion criteria, 180 (80.7%) received assessment by PoCUS during cardiac arrest management in the emergency department (ED). In the PoCUS group, 21 (11.6%) demonstrated cardiac activity and 159 (88.4%) did not. Patients with activity on PoCUS had longer mean resuscitation times (27.3; 95% confidence interval 17.7-37.0 min) than patients with no activity (11.51; 10.2-12.8 min) and patients who did not receive a PoCUS exam (14.36; 9.89-18.8 min). Patients with cardiac activity on PoCUS were more likely to receive endotracheal intubation (ET; 95.23%; 86.13-104.35%) and epinephrine (Epi; 100%; 100-100%) than patients with no activity (ET: 46.54%; 38.8-54.3%; Epi: 82.39%; 76.50-88.31%) and those with no PoCUS (ET: 65.11%; 50.87-79.36%; Epi: 81.39%; 69.76-93.03%). Those with no cardiac activity on PoCUS were much less likely to achieve ROSC (19.5%; 13.4-25.6), SHA (6.9%; 2.97-10.86%) and SHD (0.6%; -0.5-1.8%) compared to those with cardiac activity on PoCUS (ROSC; 76.19%; 57.97-94.4%), SHA (33.3%; 13.2-53.5%), SHD (9.5%; -3-22.07%), and those with no PoCUS (ROSC 39.5%; 24.9-54.1%; SHA 27.9%; 14.5- 41.3%, and SHD 6.9%; -0.6-14.59).ConclusionsEmergency department cardiac arrest patients with cardiac activity on PoCUS received longer resuscitation with higher rates of intervention as compared to those with negative findings or when no PoCUS was performed. Patients with cardiac activity on PoCUS had improved clinical outcomes as compared with patients not receiving PoCUS, and patients with no activity on PoCUS.

Interrater reliability of pediatric point-of-care lung ultrasound findings

ObjectiveWe sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia. MethodsA convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics. ResultsSeventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability. ConclusionsWe found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia.

Utility of Point-of-care Ultrasound in Children With Pulmonary Tuberculosis.

Point-of-care ultrasound (POCUS) detects extrapulmonary tuberculosis (EPTB) in HIV infected adults but has not been evaluated in children despite their higher risk of EPTB. This study's aims were to investigate feasibility of POCUS for EPTB in children, frequency of POCUS findings suggestive of EPTB and time to sonographic resolution of findings with treatment. This prospective South African cohort study enrolled children with suspected pulmonary tuberculosis (PTB). POCUS for pleural, pericardial or ascitic effusion, abdominal lymphadenopathy or splenic or hepatic microabscesses was performed and repeated at 1, 3 and 6 months of tuberculosis (TB) treatment. Prevalence of POCUS findings and their association with HIV infection was investigated in children with confirmed PTB (microbiologically proven), unconfirmed PTB (clinically diagnosed) or unlikely TB (respiratory disease that improved during follow-up without TB treatment). Of 232 children [median age 37 months (interquartile range, 18-74)], 39 (17%) were HIV infected. Children with confirmed or unconfirmed PTB had a higher prevalence of POCUS findings than children with unlikely TB [18 of 58 (31%) and 36 of 119 (30%) vs. 8 of 55 (15%); P = 0.04 and P = 0.03, respectively]. Pleural effusion [n = 30 (13%)] or abdominal lymphadenopathy [n = 28 (12%)] were the most common findings; splenic microabscesses [n = 12 (5%)] were strongly associated with confirmed PTB. Children coinfected with HIV and TB were more likely than HIV-uninfected children with TB to have abdominal lymphadenopathy (37% vs. 10%; P < 0.001) or splenic microabscesses (23% vs. 3%; P < 0.001]. Most ultrasound findings were resolved by 3 months with appropriate TB treatment. POCUS for EPTB in children with PTB is feasible. The high prevalence of findings suggests that POCUS can contribute to timely diagnosis of childhood TB and to monitoring treatment response.

The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis.

Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic value in the management of renal colic. The review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, Embase, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were computed tomography evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer. Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary. The electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full-text review, and nine articles metall inclusion criteria. Of these, five high-quality studies (N=1,773) were included in the meta-analysis for diagnostic accuracy and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% confidence interval [CI]=67.1%-73.2%) and 75.4% (95% CI=72.5%-78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta-analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI=92.7%-95.8%). Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation. Point-of-care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5mm) stone in those presenting with renal colic.

Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age

To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.

Point-of-Care Ultrasound for Extrapulmonary Tuberculosis in India: A Prospective Cohort Study in HIV-Positive and HIV-Negative Presumptive Tuberculosis Patients.

Diagnosing extrapulmonary tuberculosis (EPTB) is challenging. Point-of-care ultrasound (POCUS) for human immunodeficiency virus (HIV)-associated EPTB is applied in sub-Saharan Africa. This study aimed at evaluating the applicability of POCUS for diagnosing EPTB in HIV-positive and HIV-negative presumptive tuberculosis (TB) patients in India, a country of moderate relative TB and HIV burden. Presumptive TB patients at Kasturba Hospital, Manipal, India, prospectively underwent POCUS evaluating for pericardial, pleural and ascitic effusion, abdominal lymphadenopathy, and hepatic and splenic microabscesses. Findings were correlated with TB category (confirmed TB, clinical TB, unlikely TB), HIV status, and discharge diagnoses. A total of 425 patients underwent POCUS; 81 (20%) were HIV-positive. POCUS findings were more common in HIV/TB coinfected patients than in HIV-positive patients with unlikely TB (24/40 (60%) versus 9/41 (22%), P < 0.001). Abdominal lymphadenopathy and splenic microabscesses were strongly associated with TB in HIV-positive patients (P = 0.002 and P = 0.001). POCUS findings did not correlate with TB in HIV-negative patients; a third of HIV-negative patients with unlikely TB and POCUS findings had cancer, another third other infectious diseases. Sonographic findings were common in HIV-positive and HIV-negative presumptive TB patients. POCUS was a useful bedside test for the detection of HIV-associated EPTB. In HIV-negative patients, POCUS detected features associated with EPTB but also of malignancy and other infectious diseases.

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study

BackgroundMeasurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. ObjectiveThe primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. MethodsWe performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. ResultsA total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. ConclusionOf patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.

LO45: Does the use of point of care ultrasonography improve survival in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial

Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP&amp;lt;100 or shock index&amp;gt;1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.

LO82: The accuracy and prognostic value of point-of-care ultrasound for renal colic: a systematic review

Introduction: Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis, and 2) to assess its prognostic value in the management of renal colic (PROSPERO: 42016035331). Methods: An electronic database search of MEDLINE, EMBASE, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were CT evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by conference with a third reviewer.Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary outcome of prognostic value was reported as a narrative summary. Results: The electronic search yielded 627 unique titles. After relevance screening, 25 papers underwent full-text review, and 8 articles met all inclusion criteria. Of these, 5 high-quality studies (N=1773) were included in the meta-analysis for diagnostic accuracy, and three yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% CI=67.1% to 73.2%) and 75.4% (95% CI=72.5% to 78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect.Three studies examining prognostic value noted a higher likelihood of a large stone or surgical intervention with positive POCUS findings. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation. Conclusion: Point-of-care ultrasound is of modest accuracy for the diagnosis of nephrolithiasis. While positive POCUS findings are associated with larger stones and greater likelihood for intervention, the clinical importance of this is unclear.

Serial lung and IVC ultrasound in the assessment of congestive heart failure

BackgroundManagement of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan.ResultsFifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results.ConclusionsClinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

Septic Endocarditis and Internal Jugular Vein Thrombosis: Pocus to the Rescue

SESSION TITLE: Fellow Case Report Poster - Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Point-of-care ultrasound (POCUS) is an effective way to rapidly evaluate patients presenting with severe sepsis. We present a patient with mitral valve endocarditis and internal jugular vein thrombosis diagnosed by intensivist-performed POCUS. CASE PRESENTATION: A 44 year-old man with hypertension and end-stage renal disease on hemodialysis was found down in his shelter. He was last dialyzed five days prior to admission. He was minimally responsive on arrival to the emergency department- afebrile, blood pressure 106/87 mmHg, heart rate 140 bpm, respiratory rate 26, saturating 100% on room air. Physical exam was notable for slurred speech, facial plethora, engorged veins and asymmetric swelling in his neck, purposeless limb movements and a non-focal neuro exam. CT head showed no acute abnormality, portable chest X-ray was clear. His blood work shohwed WBC count 15K/uL with 8% bands and 78% neutrophils, lactic acid 3mmol/L, potassium 5.4mmol/L, bicarbonate 15mmol/L, blood urea nitrogen 68mg/dL, and creatinine 16.17mg/dL. He was admitted to the ICU for severe sepsis and started on broad spectrum antibiotics. POCUS revealed a large vegetation on the anterior leaflet of the mitral valve and a thrombus in the left internal jugular vein. His blood cultures grew methicillin-susceptible staphylococcus aureus. POCUS findings were confirmed on a cardiology-reviewed transthoracic echo. The patient remained encephalopathic, repeat CT head revealed new multiple areas of infarction that were consistent with septic emboli on MRI Brain. He immediately underwent mitral valve replacement with a bioprosthetic valve. He was discharged to sub-acute rehabilitation facility on hospital day 20 with marked improvement in his mental status. DISCUSSION: Patients with endocarditis with septic emboli to the brain can have resultant stroke, brain abscess, meningoencephalitis, cerebral hemorrhage, seizures, paralysis, blindness. The mortality rate for patients has been cited to be up to 74%. Our patient made a near-complete recovery due in part to timely and accurate diagnosis by POCUS. CONCLUSIONS: Although patients with neurologic sequelae of septic infective endocarditis may have poor clinical outcomes, it is possible to make a near-full recovery. This case highlights the role of POCUS in patients presenting with severe sepsis of unknown etiology. Reference #1: Roder, B.L. et. al. Neurologic manifestations of staphylococus aureus endocarditis: a review of 260 bacteremic cases in nondrug addicts. Am J Med, 1997; 102 (4): 379 DISCLOSURE: The following authors have nothing to disclose: Navitha Ramesh, Michael Lau, Jason Filopei, Paru Patrawalla No Product/Research Disclosure Information

LO040: Do combined electrocardiogram rhythm and point of care ultrasound findings predict outcome during cardiac arrest? The second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 2) Study

Introduction: Survival to hospital discharge is better for PEA than asystole in out-of-hospital cardiac arrest. Point of care ultrasound (PoCUS) is widely used in cardiac arrest, although not mandated by ACLS guidelines. This study examines if initial PoCUS findings combined with cardiac rhythm are predictive of outcomes including return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and hospital discharge (SHD). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity on PoCUS and PEA on ECG (Positive group); those with no cardiac activity recorded on PoCUS and asystole on ECG (Negative group); and those with a mix of positive and negative findings (Indeterminate group). Data was analyzed for the frequency of ROSC, SHA, and SHD. Results: 186 patients met the study criteria, with 14 (8%) in the positive group, 134 (72%) in the negative group, and 38 (20%) in the indeterminate group. The positive group had significantly better initial outcomes than the negative group: ROSC: 78% (95% CI 49-95%) vs 17% (11-25%); OR 17.70 (4.57-168.5; p &lt; 0.0001) and SHA: 29% (8-58%) vs 7% (3-12%); OR 5.56 (1.45-21.28; p = 0.022), and then the combined negative and indeterminate groups: ROSC: 22% (16-29%), OR 12.93 (3.43-48.73; p &lt; 0.0001; SHA: 8% (5-13%); OR 4.51 (1.25-16.27; p = 0.033). There was no difference between the positive group and either the negative or combined groups for final outcome of SHD: 0% (0-23%) vs 1% (0-5%); OR 1.83 (0.08-39.97; p = 1.00; and vs 1% (0-5%); OR 1.67 (0.08-33.96; p = 1.00). The negative group had worse initial outcomes than the combined positive and indeterminate groups: ROSC 17% (11-25%) vs. 50% (36-64%) OR 0.21 (0.10-0.42; p &lt; 0.0001); SHA 6% (3-12%) vs. 8% (5-13%) OR 0.34 (0.13-0.92; p = 0.0490). There was no difference in SHD: 1% (0-5%) vs. 1% (0-5%) OR 0.77 (0.07-8.71; p = 1.00). Conclusion: Our results suggest that although finding positive cardiac activity on ECG (PEA) and also on PoCUS is associated with greater ROSC and SHA, it does not identify patients with a final outcome of SHD.

Can medical learners achieve point-of-care ultrasound competency using a high-fidelity ultrasound simulator?: a pilot study

BackgroundPoint-of-care ultrasound (PoCUS) is currently not a universal component of curricula for medical undergraduate and postgraduate training. We designed and assessed a simulation-based PoCUS training program for medical learners, incorporating image acquisition and image interpretation for simulated emergency medical pathologies. We wished to see if learners could achieve competency in simulated ultrasound following focused training in a PoCUS protocol.MethodsTwelve learners (clerks and residents) received standardized training consisting of online preparation materials, didactic teaching, and an interactive hands-on workshop using a high-fidelity ultrasound simulator (CAE Vimedix). We used the Abdominal and Cardiothoracic Evaluation by Sonography (ACES) protocol as the curriculum for PoCUS training. Participants were assessed during 72 simulated emergency cardiorespiratory scenarios. Their ability to complete an ACES scan independently was assessed. Data was analyzed using R software.ResultsParticipants independently generated 574 (99.7%) of the 576 expected ultrasound windows during the 72 simulated scenarios and correctly interpreted 67 (93%) of the 72 goal-directed PoCUS scans.ConclusionsFollowing a focused training process using medical simulation, medical learners demonstrated an ability to achieve a degree of competency to both acquire and correctly interpret cardiorespiratory PoCUS findings using a high-fidelity ultrasound simulator.

Intérêt de la sEEG dans l’exploration des épilepsies occipitales. À propos d’une série de 17 cas

To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression.This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy.We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84).POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.