Point Of Care Ultrasound Protocol Research Articles

The Impact of Point-of-Care Ultrasound-Guided Resuscitation on Clinical Outcomes in Patients With Shock: A Systematic Review and Meta-Analysis.

To determine the impact of point-of-care ultrasound (POCUS)-guided resuscitation on clinical outcomes in adult patients with shock. We searched MEDLINE, Embase, and unpublished sources from inception to December 2023. We included randomized controlled trials (RCTs) that examined the use of POCUS to guide resuscitation in patients with shock. We collected data regarding study and patient characteristics, POCUS protocol, control group interventions, and outcomes. We identified 18 eligible RCTs. POCUS slightly influences physicians' plans for IV fluid (IVF) and vasoactive medication prescription (moderate certainty), but results in little to no changes in the administration of IVF (low to high certainty) or inotropes (high certainty). POCUS may result in no change in the number of CT scans performed (low certainty) but probably reduces the number of diagnostic echocardiograms performed (moderate certainty). POCUS-guided resuscitation probably reduces 28-day mortality (relative risk [RR] 0.88; 95% CI, 0.78-0.99), the duration of vasoactive medication (mean difference -0.73 d; 95% CI, -1.16 to -0.30), and the need for renal replacement therapy (RRT) (RR 0.80; 95% CI, 0.63-1.02) (low to moderate certainty evidence), and lactate clearance (high certainty evidence). POCUS-guided resuscitation may results in little to no difference in ICU or hospital admissions, ICU and hospital length of stay, and the need for mechanical ventilation (MV) (low to moderate certainty evidence). There is an uncertain effect on the risk of acute kidney injury and the duration of MV or RRT (very low certainty evidence). POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.

Point of care ultrasound for triage of critically ill patients in the emergency department

Point of care ultrasound (POCUS) has been a constantly evolving and growing tool utilized by emergency medicine and intensive care practitioners. Ultrasound use for the assessment and management of critically ill patients has been available for several decades with the focused assessment with sonography in trauma (FAST) exam being one of the first widely adopted POCUS protocols. This along with other established protocols has made an impact on the care delivered to critically ill patients. This narrative review will cover some of the history of POCUS in the emergency department, brief considerations for machines and infrastructure, and current uses including in trauma, shock/hypotension, cardiac arrest, dyspnea, abdomen, vascular, and procedural guidance. Furthermore, it will provide a review of the evidence supporting its efficacy in managing critically ill patients and future directions.

Artificial Intelligence (AI) Applications for Point of Care Ultrasound (POCUS) in Low-Resource Settings: A Scoping Review.

Advancements in artificial intelligence (AI) for point-of-care ultrasound (POCUS) have ushered in new possibilities for medical diagnostics in low-resource settings. This review explores the current landscape of AI applications in POCUS across these environments, analyzing studies sourced from three databases-SCOPUS, PUBMED, and Google Scholars. Initially, 1196 records were identified, of which 1167 articles were excluded after a two-stage screening, leaving 29 unique studies for review. The majority of studies focused on deep learning algorithms to facilitate POCUS operations and interpretation in resource-constrained settings. Various types of low-resource settings were targeted, with a significant emphasis on low- and middle-income countries (LMICs), rural/remote areas, and emergency contexts. Notable limitations identified include challenges in generalizability, dataset availability, regional disparities in research, patient compliance, and ethical considerations. Additionally, the lack of standardization in POCUS devices, protocols, and algorithms emerged as a significant barrier to AI implementation. The diversity of POCUS AI applications in different domains (e.g., lung, hip, heart, etc.) illustrates the challenges of having to tailor to the specific needs of each application. By separating out the analysis by application area, researchers will better understand the distinct impacts and limitations of AI, aligning research and development efforts with the unique characteristics of each clinical condition. Despite these challenges, POCUS AI systems show promise in bridging gaps in healthcare delivery by aiding clinicians in low-resource settings. Future research endeavors should prioritize addressing the gaps identified in this review to enhance the feasibility and effectiveness of POCUS AI applications to improve healthcare outcomes in resource-constrained environments.

Comments and Illustrations of Ultrasound Findings in Extrapulmonary Tuberculosis Manifestations.

This review describes the appearance of extrapulmonary tuberculosis manifestations in comprehensive and multiparametric ultrasound imaging. The aim is to increase awareness of typical ultrasound findings regarding extrapulmonary tuberculosis, correlate those with pathological features, and facilitate differential diagnosis. Point of care ultrasound protocols can be used as a screening method in high-risk populations, although the negative findings do not exclude tuberculosis. Conversely, the diagnosis of extrapulmonary tuberculosis can never be made using ultrasound alone, as many ultrasound findings in extrapulmonary tuberculosis are non-specific. However, ultrasound-based sampling techniques can significantly facilitate the collection of samples for microbiological or molecular proof of tuberculosis, as well as facilitating the establishment of alternative diagnoses.

Handheld Lung Ultrasound to Detect COVID-19 Pneumonia in Inpatients: A Prospective Cohort Study.

Background: Chest imaging, including chest X-ray (CXR) and computed tomography (CT), can be a helpful adjunct to nucleic acid test (NAT) in the diagnosis and management of Coronavirus Disease 2019 (COVID-19). Lung point of care ultrasound (POCUS), particularly with handheld devices, is an imaging alternative that is rapid, highly portable, and more accessible in low-resource settings. A standardized POCUS scanning protocol has been proposed to assess the severity of COVID-19 pneumonia, but it has not been sufficiently validated to assess diagnostic accuracy for COVID-19 pneumonia. Purpose: To assess the diagnostic performance of a standardized lung POCUS protocol using a handheld POCUS device to detect patients with either a positive NAT or a COVID-19-typical pattern on CT scan. Methods: Adult inpatients with confirmed or suspected COVID-19 and a recent CT were recruited from April to July 2020. Twelve lung zones were scanned with a handheld POCUS machine. Images were reviewed independently by blinded experts and scored according to the proposed protocol. Patients were divided into low, intermediate, and high suspicion based on their POCUS score. Results: Of 79 subjects, 26.6% had a positive NAT and 31.6% had a typical CT pattern. The receiver operator curve for POCUS had an area under the curve (AUC) of 0.787 for positive NAT and 0.820 for a typical CT. Using a two-point cutoff system, POCUS had a sensitivity of 0.90 and 1.00 compared to NAT and typical CT pattern, respectively, at the lower cutoff; it had a specificity of 0.90 and 0.89 compared to NAT and typical CT pattern at the higher cutoff, respectively. Conclusions: The proposed lung POCUS protocol with a handheld device showed reasonable diagnostic performance to detect inpatients with a positive NAT or typical CT pattern for COVID-19. Particularly in low-resource settings, POCUS with handheld devices may serve as a helpful adjunct for persons under investigation for COVID-19 pneumonia.

Evaluation of remote radiologist-interpreted point-of-care ultrasound for suspected dengue patients in a primary health care facility in Colombia

BackgroundEarly identification of plasma leakage may guide treatment decisions in dengue patients. This study evaluated the value of point-of-care ultrasound (POCUS) to detect plasma leakage and predict hospitalization or referral to a higher level of care in suspected dengue patients under routine conditions at a primary care facility in Colombia.MethodsWe conducted a cohort study between April 2019 and March 2020 in a primary care hospital in Cali, Colombia. We prospectively included and followed 178 patients who were at least 2 years old with fever of less than 10 days and clinician-suspected dengue. A trained general practitioner performed a standardized POCUS protocol. Images were quality-rated and overread by an expert radiologist, and her results and those of the general practitioner were compared using the Kappa index. Logistic regression was used to identify factors associated with plasma leakage at enrollment and explore its prognostic value regarding hospital admission or referral to a higher level of care.ResultsHalf (49.6%) POCUS images were of suitable quality to be interpreted. The proportion of plasma leakage reported by the radiologist was 85.1% (95% CI: 78.6–90.2%) and 47.2% by the study physician (Kappa = 0.25, 95% CI: 0.15–0.35). The most frequent ultrasound findings were ascites (hepatorenal 87.2%, splenorenal 64%, or pelvic 21.8%) and gallbladder wall thickening (10.5%). Plasma leakage was higher in subjects with thrombocytopenia (aOR = 4, 95% CI: 1.3–12.1) and lower in patients 30–59 years old (aOR = 0.1, 95% CI: 0.0–0.4) than in those 18 years old or younger. POCUS evidence of plasma leakage (aOR = 8.2, 95% CI: 2.2–29.9), thrombocytopenia (aOR = 6.3, 95% CI: 2.4–16.0) and pulse pressure (aOR = 1.1, 95% CI: 1.07–1.2) were associated with hospital admission or referral to a higher level of care.ConclusionsUltrasound is useful to detect plasma leakage in primary care and, challenges remain to guarantee high-quality images and diagnostic accuracy, for which a standardized dengue POCUS protocol and training program is needed.Graphical

Implementing an interprofessional point-of-care ultrasound protocol for dyspneic patients in an emergency department as a blended learning concept-Feasibility of Employing Thoracic Ultrasound in Shortness of Breath.

Dyspnea is a common symptom in the Emergency Department, with a wide variety of differential diagnoses. Previous research has demonstrated the diagnostic accuracy of Point-of-Care Ultrasound (POCUS) in this field of interest. Our goal was to better establish sonography in our emergency department with a practicable and time effective method. Therefore, we implemented a sonography protocol in an interprofessional emergency team using blended learning as a modern didactic approach and evaluated the learning and teaching success. We named the study FETUS, which stands for "Feasibility of Employing Thoracic Ultrasound in Shortness of Breath." A demonstration of the POCUS protocol was given, followed by individual supervision during clinical routine. A written manual, a pocket card, and further materials for personal training supplemented the training. A post-training questionnaire measured several parameters regarding the training, e.g., subjective skill-acquisition or media use. 32 medical and nursing staff participated in this study, 14 of whom completed the questionnaire. All training modalities offered were well received. A pre-post comparison of subjective sonographic competence shows a significant increase in both medical and nursing staff.The other items surveyed also indicate the success of the intervention undertaken. The use of different media as a blended learning approach can support the implementation of new measures in the ongoing working routine within an interprofessional team.

Multiorgan Point-of-Care Ultrasound Assessment in Critically Ill Adults.

Traditional point-of-care ultrasound (POCUS) training highlights discrete techniques, single-organ assessment, and focused protocols. More recent developments argue for a whole-body approach, where the experienced clinician-ultrasonographer crafts a personalized POCUS protocol depending on specific clinical circumstances. This article describes this problem-based approach, focusing on common acute care scenarios while highlighting practical considerations and performance characteristics.

Feasibility of a point-of-care ultrasound protocol for cardiorespiratory evaluation of horses in different clinical settings.

A point-of-care ultrasound (POCUS) protocol for evaluation of the cardiac and respiratory systems in horses does not exist. (a) Describe the windows of a POCUS protocol for cardiorespiratory assessment of horses (CRASH); (b) Estimate the number of acoustic windows that can be acquired by a sonographer-in-training; (c) Estimate the time required to complete the protocol for specific groups of horses; (d) Describe the sonographic abnormalities detected in horses presented with cardiovascular, respiratory, or systemic disease. Twenty-seven healthy horses, 14 horses competing in athletic events, and 120 horses with clinical disease. A pocket-sized ultrasound device was used to acquire 7 sonographic cardiorespiratory windows in various clinical scenarios. The duration of the examination was timed, and images were evaluated for diagnostic quality. Abnormalities in horses with clinical disease were determined by an expert sonographer. The CRASH protocol could be performed in healthy and diseased horses in hospital, barn, and competition settings between 5.5 ± 0.9 (athletic horses) and 6.9 ± 1.9min (horses with clinical disease). Thoracic windows were obtained most consistently, followed by right parasternal long-axis echocardiographic windows. Frequently detected abnormalities were pleural fluid, lung consolidation, B-lines, and moderate-to-severe left-sided heart disease. The CRASH protocol was feasible using a pocket-sized ultrasound device in various groups of horses, could be completed rapidly in a variety of settings, and frequently identified sonographic abnormalities when evaluated by an expert sonographer. The diagnostic accuracy, observer agreement, and utility of the CRASH protocol merit further evaluation.

Point-of-Care Ultrasound Fracture-Physis Distance Association with Salter-Harris II Fractures of the Distal Radius in Children: The "POCUS 1-cm Rule".

Salter-Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture-physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter-Harris II fractures, compared with other fracture types, in a cohort of children with X-ray-identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray-identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture-physis distance. The median and maximum fracture-physis distances for Salter-Harris II fractures (n=19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n=22) were 10.20 and 15.98 mm, and those for complete fractures (n=9) were 10.85 and 12.85 mm. Buckle fracture (n=72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture-physis distance cutoff of 1 cm differentiated Salter-Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the "POCUS 1-cm rule" could be used as a secondary sign to augment the diagnosis of Salter-Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively.

Point of Care Ultrasonography for the Septic Patient in the Emergency Department: A Literature Review.

The point-of-care ultrasound (POCUS) has been effectively used in intensive care units for the management of septic patients. Since it is a time- and cost-effective non-invasive imaging modality, its use in the emergency department (ED) has been advocated for by medical experts. This review summarizes the existing literature regarding the breadth of POCUS as a supplementary tool to the holistic approach of septic patients in the ED setting. A literature search was conducted via PubMed (MEDLINE), Cochrane Library, and Scopus databases, analyzing studies which examined the use of POCUS in the ED for non-traumatic, septic, and/or undifferentiated hypotensive patients, resulting in 26 studies. The first cluster of studies investigates the efficiency of POCUS protocols in the differential diagnosis and its reliability for distributive/septic shock and sepsis management. In the second cluster, POCUS use results in faster sepsis cause identification and improves therapeutic management. The third cluster confirms that POCUS aids in the accurate diagnosis and management, even in rare and complicated cases. The results of the present review support the well-documented utility of POCUS and highlight the importance of POCUS incorporation in the comprehensive management of the septic patient in the ED setting.

Ultrasound during the COVID-19 Pandemic: A Global Approach.

SARS-CoV-2 (severe acute respiratory syndrome Coronavirus-2) rapidly spread worldwide as COVID-19 (Coronavirus disease 2019), causing a costly and deadly pandemic. Different pulmonary manifestations represent this syndrome's most common clinical manifestations, together with the cardiovascular complications frequently observed in these patients. Ultrasound (US) evaluations of the lungs, heart, and lower limbs may be helpful in the diagnosis, follow-up, and prognosis of patients with COVID-19. Moreover, POCUS (point-of-care ultrasound) protocols are particularly useful for patients admitted to intensive care units. The present review aimed to highlight the clinical conditions during the SARS-CoV-2 pandemic in which the US represents a crucial diagnostic tool.

Detecting spontaneous retroperitoneal hemorrhage using a modified RUSH protocol: a case report.

IntroductionBleeding in the retroperitoneal space is a serious complication. Hypovolemia and shock develop late after losing a large volume of blood. However, point of care ultrasound (POCUS) examinations in adult patients with shock do not include the retroperitoneal space.Case presentationWe present the case of a 74-year-old male with ischemic heart disease on dual antiplatelet. He developed vague abdominal pain and hemoglobin drop without overt bleeding source until he developed shock. Modified POCUS examination that included the retroperitoneal space detected the bleeding source and confirmed later by computerized tomography of the abdomen. The case was managed conservatively.Clinical discussionThe risk factors associated with the formation of spontaneous retroperitoneal hematomas are age above 70 years and dual antiplatelet therapy. The initial integration of point-of-care ultrasound into the assessment of shocked patients leads to an earlier and accurate initial diagnosis with a clear patient care plan. POCUS should include the retroperitoneal space examination in every patient presenting with shock.ConclusionIn patients with unexplained hemorrhagic shock, a modified POCUS protocol could help by including an examination of the retroperitoneal space in the assessment.

ENHANCING CARDIO-PULMONARY IMAGING ACCESS TO A FIRST NATIONS CARE SETTING USING POINT-OF-CARE ULTRASOUND AND REMOTE LIVE-STREAMING

BACKGROUND Point-of-care ultrasound (POCUS) has revolutionized the clinical examination by providing the ability to accurately assess the heart and lungs at the bedside. It is recommended by the American Society of Echocardiography (ASE) as the first-line imaging tool for patients with suspected COVID-19 and cardiopulmonary symptoms. However, physicians practicing in remote or low-resource settings often do not have access to training opportunities. These challenges have been exacerbated by the pandemic. Live-streaming technology offers a novel opportunity to reach physicians that otherwise would be precluded from these opportunities. Our objective was to implement a fully virtual, live-streamed ultrasound teaching and tele-consultation service for non-conventional users of cardiopulmonary ultrasound in an underserviced care setting. METHODS AND RESULTS Physicians with no prior POCUS training at the Kingston Health Sciences Centre and the Weeneebayko General Hospital in Moose Factory, Ontario, were recruited to participate in a 3-week virtual POCUS training program (Fig. 1). All learners completed three e-learning modules based on the ASE COVID-19 POCUS protocol for COVID-19 and participated in a live-streamed virtual workshop led by expert educators. They then received 6-10 individualized, live-streamed tele-POCUS mentorship sessions using novel technology (Philips Lumify ultrasound and audio/video streams via Reacts software), and were evaluated through expert-assessed virtual tests. The primary outcome used to assess learner competence and knowledge retention was the average change in pre- and post-training test scores. All testing components were scored on a 5-point Likert scale. 16 physicians have been enrolled to date, including five family physicians in Moose Factory. In total, 82 tele-POCUS mentorship sessions have been conducted and 9 participants have completed the program. The average improvement between pre- and post-tests among participants who have finished was statistically significant for both cardiac (Average Likert score improved 2.5 to 4.1, p < 0.001) and lung ultrasound (Average Likert score improved 3.1 to 4.3, p < 0.001) components. All novice, remote users demonstrated improvement in device operation, image optimization, and acquisition following the training program despite no face-to-face contact with instructors. CONCLUSION Introductory POCUS skills can be taught to remote users using an entirely virtual, live-streamed format. We have demonstrated that this technology can be used to train physicians regardless of location, and offers a novel method for distributing POCUS skills to remote and low resource settings in Canada. Point-of-care ultrasound (POCUS) has revolutionized the clinical examination by providing the ability to accurately assess the heart and lungs at the bedside. It is recommended by the American Society of Echocardiography (ASE) as the first-line imaging tool for patients with suspected COVID-19 and cardiopulmonary symptoms. However, physicians practicing in remote or low-resource settings often do not have access to training opportunities. These challenges have been exacerbated by the pandemic. Live-streaming technology offers a novel opportunity to reach physicians that otherwise would be precluded from these opportunities. Our objective was to implement a fully virtual, live-streamed ultrasound teaching and tele-consultation service for non-conventional users of cardiopulmonary ultrasound in an underserviced care setting. Physicians with no prior POCUS training at the Kingston Health Sciences Centre and the Weeneebayko General Hospital in Moose Factory, Ontario, were recruited to participate in a 3-week virtual POCUS training program (Fig. 1). All learners completed three e-learning modules based on the ASE COVID-19 POCUS protocol for COVID-19 and participated in a live-streamed virtual workshop led by expert educators. They then received 6-10 individualized, live-streamed tele-POCUS mentorship sessions using novel technology (Philips Lumify ultrasound and audio/video streams via Reacts software), and were evaluated through expert-assessed virtual tests. The primary outcome used to assess learner competence and knowledge retention was the average change in pre- and post-training test scores. All testing components were scored on a 5-point Likert scale. 16 physicians have been enrolled to date, including five family physicians in Moose Factory. In total, 82 tele-POCUS mentorship sessions have been conducted and 9 participants have completed the program. The average improvement between pre- and post-tests among participants who have finished was statistically significant for both cardiac (Average Likert score improved 2.5 to 4.1, p < 0.001) and lung ultrasound (Average Likert score improved 3.1 to 4.3, p < 0.001) components. All novice, remote users demonstrated improvement in device operation, image optimization, and acquisition following the training program despite no face-to-face contact with instructors. Introductory POCUS skills can be taught to remote users using an entirely virtual, live-streamed format. We have demonstrated that this technology can be used to train physicians regardless of location, and offers a novel method for distributing POCUS skills to remote and low resource settings in Canada.

Point-of-care ultrasound (POCUS) practices in the helicopter emergency medical services in Europe: results of an online survey

BackgroundThe extent to which Point-of-care of ultrasound (POCUS) is used in different European helicopter EMS (HEMS) is unknown. We aimed to study the availability, perception, and future aspects of POCUS in the European HEMS using an online survey.MethodA survey about the use of POCUS in HEMS was conducted by a multinational steering expert committee and was carried out from November 30, 2020 to December 30, 2020 via an online web portal. Invitations for participation were sent via email to the medical directors of the European HEMS organizations including two reminding notes.ResultsDuring the study period, 69 participants from 25 countries and 41 different HEMS providers took part in the survey. 96% (n = 66) completed the survey. POCUS was available in 75% (56% always when needed and 19% occasionally) of the responding HEMS organizations. 17% were planning to establish POCUS in the near future. Responders who provided POCUS used it in approximately 15% of the patients. Participants thought that POCUS is important in both trauma and non-trauma-patients (73%, n = 46). The extended focused assessment sonography for trauma (eFAST) protocol (77%) was the most common protocol used. A POCUS credentialing process including documented examinations was requested in less than one third of the HEMS organizations.ConclusionsThe majority of the HEMS organizations in Europe are able to provide different POCUS protocols in their services. The most used POCUS protocols were eFAST, FATE and RUSH. Despite the enthusiasm for POCUS, comprehensive training and clear credentialing processes are not available in about two thirds of the European HEMS organizations. Due to several limitations of this survey further studies are needed to evaluate POCUS in HEMS.

The Hybrid POCUS-to-Echo Feasibility Study: Provision of Expedited Cardiac Point of Care Ultrasound Service (e-POCUS) by the Echocardiography Lab.

Background: Comprehensive transthoracic echocardiography (CTE) provides information vital to the care of acutely ill and unstable patients, but may not be readily available. Cardiac point of care ultrasound (POCUS) is well suited to providing key information at the bedside to expedite decision making. Our objective was to evaluate the feasibility of expedited-POCUS (e-POCUS) provided by the echo lab for internal medicine, cardiology and intensive care services. Methods: A new e-POCUS service was developed by the Kingston Health Sciences Center Echo Lab, whereby focused information relevant to 4 clinical situations (acute heart failure, tamponade, shock and suspected acute valvulopathy) would be provided urgently at the bedside. Requests were acquired over a 4 month period. Sonographers were immediately deployed on request and followed a standard POCUS protocol for each scenario. Staff echocardiographers provided immediate interpretation and arranged for further imaging at their discretion. The response time, diagnostic accuracy and clinical utility of e-POCUS was assessed. Results: A total of 18 patients were evaluated. The average time of an e-POCUS exam was 10 minutes and the average e-POCUS to formal CTE timing was 1.3 days. The agreement between e-POCUS and CTE for the presence of segmental wall motion abnormalities was 83% (Kappa=0.61, p=0.009) and 72% for the detection of right ventricular dilatation (Kappa =0.44, p=0.058). The e-POCUS results altered the working diagnosis in 72% of cases. Conclusion: The provision of an e-POCUS service by the Echo Lab is a feasible workflow solution meeting the demands of a new practice pattern.

LO82: Exploring eye-tracking technology to assess competency in point-of-care ultrasound

Introduction: Assessment of point-of-care ultrasound (POCUS) competency has been reliant on practical, visual and written examinations performed 1-on-1 with an examiner. These tools attempt to assess competency through subjective ratings, checklists and multiple-choice questions that are labour intensive using surrogate measures. Eye-tracking has been used on a limited basis in various fields of medicine for training and assessment. This technology explores visual processing and holds great promise as a tool to monitor training progress towards the development of expertise. We hypothesize that eye-tracking may differentiate novices and experts as they progress to become competent in interpretation of POCUS images and provide an objective measure in assessment of competency. Methods: Medical students, residents and attending physicians working in an academic emergency department were recruited. Participants viewed a series of 16 ultrasound video clips in a POCUS protocol for Focused Assessment using Sonography in Trauma (FAST). The gaze pattern of the participants was recorded using a commercially available eye-tracking device. The primary outcome was the gaze parameters including total gaze time in the area of interest (AOI), average time to fixation on the AOI, number of fixations in the AOI and average duration of first fixation on the AOI. Secondary outcome was the accuracy on the interpretation of the FAST scan. Results: Four novices and eight experts completed this study. The total gaze time in the AOI (mean +/- SD) was 76.72 +/- 18.84s among experts vs 53.64 +/- 10.33s among novices (p = 0.048), average time to fixation on the AOI was 0.561 +/- 0.319s vs 1.048 +/- 0.280s (p = 0.027), number of fixations in the AOI was 158.9 +/- 29.0 vs 121.8 +/- 17.5 (p = 0.042) and average duration of first fixation was 0.444 +/- 0.119s vs 0.390 +/- 0.024s (p = 0.402). The accuracy of the answers was 79.7 +/- 14.1% vs 45.3 +/- 21.9% (p = 0.007). Conclusion: In this pilot study, eye tracking shows potential to differentiate between POCUS experts and novices by their gaze patterns. Gaze patterns captured by eye tracking may not necessarily translate to cognitive processing. However, it allows educators to visualise the thought processes of the learner by their gaze patterns and provide insight on how to guide them towards competency. Future studies are needed to further validate the metrics for competency in POCUS applications.

Point-of-care ultrasound (POCUS) in a remote area of Sierra Leone: impact on patient management and training program for community health officers.

Point-of-care ultrasound (POCUS) has been shown to have unique potential in low-income countries. Physicians and other healthcare providers can perform effective scans after a short period of training. This study aimed to evaluate indications and utility of ultrasonography as the main imaging service in a poor rural sub-Saharan region of Africa. Second, it evaluated the effect of a short training on POCUS for non-physician health providers and their agreement with a group of Italian physicians. This study was undertaken in Lokomasama-a chiefdom of Sierra Leone-between January and February 2019. Based on clinical indications, ultrasound findings were evaluated with respect to the initial diagnostic hypothesis. Volunteer doctors conducted a theoretical-practical training of two community health officers (CHO) on chest and abdominal POCUS and E-FAST protocol. The evaluation of the achieved technical skills was obtained with a numeric score. Inter-observer agreement concerning ultrasound diagnosis based on clinical indications was assessed. A total of 196 consecutive patients underwent ultrasound examination. POCUS findings were in keeping with the clinical diagnosis in the 49.5%. POCUS changed the initial diagnosis in 17% of cases. After training, E-FAST and POCUS knowledge score was 90% and 83%, respectively. An excellent inter-observer agreement (0.88) was found between CHOs and physicians. POCUS represents a powerful diagnostic tool in a low-income country that may improve the patient management. Training of non-physician health providers is doable and may improve healthcare management in resource-limited settings.

Accuracy of Point-of-care Ultrasound for Diagnosing Soft Tissue Abscess.

Over 3 million cases of skin and soft tissue infections (SSTIs) including cellulitis and abscesses are managed in U.S. emergency departments (EDs) each year.1-4 Overlap in presentations of cellulitis and abscess, which require different therapeutic approaches, has prompted increasing research into point-of-care ultrasound (POCUS) to help differentiate the two.2, 5, 6 The systematic review summarized here included prospective cohort studies evaluating POCUS for diagnosis of abscess in ED patients.7 The authors of the systematic review included patients with clinical evidence of SSTI. Reference standards varied, typically including draining purulent discharge, computed tomography scan, or clinical follow-up. There were no restrictions with regard to POCUS machine, transducer, protocol, or clinician background. The primary outcome was diagnostic accuracy for abscess in the ED. The authors identified eight relevant studies (n = 747 patients), with three conducted in adult ED and five in pediatric ED. Calculation of the point estimates for the diagnostic accuracy of POCUS found a sensitivity of 95.5% (95% confidence interval [CI] = 88.9 to 98.3) and specificity of 80.3% (95% CI = 56.4 to 92.7).8 There are important limitations to the validity of these data. First, patients with cellulitis but initially negative POCUS for abscess may develop abscess later, confounding the reported results. Second, the included studies incorporated various criterion standards for abscess diagnosis due to absence of a definitive criterion. Perhaps more importantly, this review included few studies, all with convenience samples, routine contamination between clinicians and sonographers (for both diagnosis and management decisions), and shifting reference standards. These methodologic challenges tend to inflate sensitivity and specificity estimates, a concern highlighted by findings from both the largest study in the systematic review and a larger study published after the review.9, 10 The largest study included in the analysis, comprising 25% of the review's sample size, found that POCUS did not add to the diagnostic posttest probability (and may have lowered both sensitivity and specificity) when clinicians felt confident of the diagnosis before ultrasound (i.e., when pretest probability was high). However, when the pretest probability was low or moderate, ultrasound was found to be helpful in increasing the posttest probability.9 Similarly, a large recent study reported that when clinicians felt certain (>90% of cases) of the diagnosis, ultrasound was unhelpful, while in most uncertain cases it improved accuracy.10 Based on this evidence, the accuracy numbers reported in the systematic review do not appear reliably valid for typical or common POCUS use in SSTI. We believe that the diagnostic accuracy of POCUS is dependent on the pre-test probability of abscess. POCUS does appear, however, to be potentially helpful in identifying abscess in ED patients in cases of diagnostic uncertainty. Therefore, we have assigned a color recommendation of yellow (unclear if benefits), although we recognize that POCUS is helpful in cases with clinical uncertainty after clinical examination.

Point-of-care Ultrasonography for Detecting the Etiology of Unexplained Acute Respiratory and Chest Complaints in the Emergency Department: A Prospective Analysis.

Introduction Point-of-care ultrasound (POCUS) is increasingly used as a diagnostic tool in emergency departments. As the number and type of POCUS protocols expand, there is a need to validate their efficacy in comparison with current diagnostic standards. This study compares POCUS to chest radiography in patients with undifferentiated respiratory or chest complaints.MethodsA prospective convenience sample of 59 adult patients were enrolled from those presenting with unexplained acute respiratory or chest complaints (and having orders for chest radiography) to a single emergency department in an academic tertiary-care hospital. After a brief educational session, a medical student, blinded to chest radiograph results, performed and interpreted images from the modified Rapid Assessment of Dyspnea in Ultrasound (RADiUS) protocol. The images were reviewed by a blinded ultrasound fellowship-trained emergency physician and compared to chest radiography upon chart review. The primary “gold standard” endpoint diagnosis was the diagnosis at discharge. A secondary analysis was performed using the chest computed tomography (CT) diagnosis as the endpoint diagnosis in the subset of patients with chest CTs.ResultsWhen using diagnosis at discharge as the endpoint diagnosis, the modified RADiUS protocol had a higher sensitivity (79% vs. 67%) and lower specificity (71% vs. 83%) than chest radiography. When using chest CT diagnosis as the endpoint diagnosis (in the subset of patients with chest CTs), the modified RADiUS protocol had a higher sensitivity (76% vs. 65%) and lower specificity (71% vs. 100%) than chest radiography. The medical student performed and interpreted the 59 POCUS scans with 92% accuracy.ConclusionThe sensitivity and specificity of POCUS using the modified RADiUS protocol was not significantly different than chest radiography. In addition, a medical student was able to perform the protocol and interpret scans with a high level of accuracy. POCUS has potential value for diagnosing the etiology of undifferentiated acute respiratory and chest complaints in adult patients presenting to the emergency department, but larger clinical validation studies are required.