Sonography For Trauma Examination Research Articles

Point-of-Care Ultrasonography in the Critical Care Setting: Abdominal POCUS.

Point-of-care ultrasonography is becoming standard practice for diagnosis and management of patients in the critical care setting. When using point-of-care ultrasonography for evaluation of the abdomen, most providers will immediately think of the Focused Assessment with Sonography for Trauma examination. However, there are a number of important abdominal applications for the nontrauma patient, including evaluation of the function of abdominal organs, differentiation of shock states, and identification of sources of sepsis. This article covers basic approaches to an abdominal point-of-care ultrasonography examination of the biliary tract, liver, kidneys, bladder, and appendix, as well as identification and management of intra-abdominal free fluid.

Point-of-Care Ultrasonography in the Intensive Care Unit for the Obstetric Patient.

Point-of-care ultrasonography (POCUS) is a tool that can be used to evaluate critically ill obstetric patients, in the same way as for nonpregnant patients. With knowledge of the physiology and anatomical changes of pregnancy, POCUS can provide meaningful information to help guide clinical management. A POCUS cardiothoracic evaluation for left and right ventricular function, pulmonary edema, pleural effusion, and pneumothorax can be performed in pregnancy. A Focused Assessment with Sonography in Trauma examination in pregnancy is performed similarly to that in nonpregnant patients, and the information obtained can guide decision-making regarding operative versus nonoperative management of trauma. POCUS is also used to glean important obstetric information in the setting of critical illness and trauma, such as fetal status, gestational age, and placental location. These obstetric evaluations should be performed rapidly to minimize delay and enable pregnant patients to receive the same care for critical illness and trauma as nonpregnant patients.

Ultrasound Rounds: Anesthesiologist-Performed Intraoperative Point-of-Care Focused Assessment With Sonography in Trauma Examination Changes Surgical Management.

Focused Assessment with Sonography in Trauma (FAST) examinations have been performed for decades by surgeons during initial patient presentation for emergency care and surgical planning, as well as for guiding resuscitation. This case highlights how use of intraoperative FAST examinations performed by anesthesiologists can dramatically change patient management. Use by anesthesiologists perioperatively is an important skill, although it is not widely practiced.

Implanted Penile Prosthetic Visualized During Focused Assessment with Sonography for Trauma Examination: A Case Report.

This is a case report of an implanted penile prosthetic visualized during focused assessment with sonography for trauma (FAST) examination. The case represents a unique finding near the lateral bladder that may confound assessment of intraperitoneal fluid collections during initial assessment of trauma patients. A 61-year-old Black male was brought to the emergency department from a nursing facility for evaluation after sustaining a ground-level fall. A FAST exam demonstrated an abnormal fluid collection anterior and lateral to the bladder, later identified as an implanted penile prosthetic. Focused assessment with sonography for trauma examinations are often performed on unidentified patients in a time-sensitive manner. Understanding of potential false-positive results is crucial to appropriate use of the tool. This report demonstrates a novel false-positive result that may be difficult to differentiate from a true intraperitoneal bleed.

Con: Limitations of POCUS Examination: Be Aware of Overdiagnosis and Undertreatment

ULTRASOUND IS A REVOLUTIONARY, noninvasive imaging tool that, when used and interpreted by trained personnel in the proper clinical situation, can provide correct diagnosis and treatment. Point-of-care ultrasound (POCUS) is defined as a handheld, mobile, broadly applied ultrasound machine capable of performing limited studies at bedside to provide answers to focused, closed-ended, binary questions. 1 Baribeau Y Sharkey A Chaudhary O et al. Handheld point-of-care ultrasound probes: The New generation of POCUS. J Cardiothorac Vasc Anesth. 2020; 34: 3139-3145 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar , 2 Reisinger NC Koratala A. Incorporating training in POCUS in nephrology fellowship curriculum. Clin J Am Soc Nephrol. 2022; 17: 1442-1445 Crossref PubMed Scopus (0) Google Scholar Over the last 15 years, the medical literature has demonstrated the importance of this tool in medical practice, 3 Miller DL Abo A Abramowicz JS et al. Diagnostic ultrasound safety review for point-of-care ultrasound practitioners. J Ultrasound Med. 2020; 39: 1069-1084 Crossref PubMed Scopus (17) Google Scholar with applications including delineation of airway structures, lung pathology, cardiac structure and function, gastric volume and content, guided vascular procedures, and emergent focused assessment with sonography for trauma examination. 4 Kalagara H Coker B Gersterin NS et al. Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist. J Cardiothorac Vasc Anesth. 2022; 36: 1132-1147 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar However, this readily accessible tool cannot completely replace patient history, physical examination, clinical judgment, and other formal imaging modalities read by a specialist for the diagnosis, monitoring, and treatment of patient clinical status. There is a concern for overdiagnosis and undertreatment of various clinical pathologies using POCUS, and future direction is needed to optimize this diagnostic tool and prevent overdiagnosis and undertreatment.

Point-of-care ultrasound use in emergencies: what every anaesthetist should know.

Point-of-care ultrasound has been embraced by anaesthetists as an invaluable tool for rapid diagnosis of haemodynamic instability, to ensure procedural safety and monitor response to treatments. Increasingly available, affordable and portable, with emerging evidence of improved patient outcomes, point-of-care ultrasound has become a valuable tool in the emergency setting. This state-of-the-art review describes the feasibility of point-of-care ultrasound practice, training and maintenance of competence. It also describes the many uses of point-of-care ultrasound for the anaesthetist and describes the most salient point-of-care ultrasound views for anaesthetic emergencies including: undifferentiated shock; hypoxemia; and trauma. Procedural safety is also discussed in addition to relevant important governance aspects. Cardiac function should be assessed using the parasternal long axis, parasternal short basal/mid-papillary/apical, apical four chamber and subcostal four chamber views, and should include a visual estimation of global left ventricular ejection fraction. Other cardiovascular conditions that can be identified using point-of-care ultrasound include: pericardial effusion; cardiac tamponade; and pulmonary embolism. Pulmonary emergency conditions that can be diagnosed using point-of-care ultrasound include pneumothorax; pleural effusion; and interstitial syndrome. The extended focused assessment with sonography for trauma examination may of value in patients who are hypotensive in order to identify intra-abdominal haemorrhage, pneumothoraces and haemothoraces.

Dissemination and Use of Point-of-Care Ultrasound by Pediatricians in Europe: A Research in European Pediatric Emergency Medicine Network Collaborative Survey.

We surveyed the dissemination and use of point-of-care ultrasound (POCUS), physician training levels, and barriers and limitations to use of POCUS among pediatricians and pediatric emergency medicine (PEM) physicians across Europe and Israel. A questionnaire was distributed through the PEM section of the European Society for Emergency Medicine and the Research in European Pediatric Emergency Medicine Network. A total of 581 physicians from 22 countries fully completed the questionnaire. Participants were primarily pediatric attending physicians (34.9% [203 of 581]) and PEM attending physicians (28.6% [166 of 581]). Most of the respondents, 58.5% (340 of 581), reported using POCUS in their practice, and 61.9% (359/581) had undergone POCUS training. Point-of-care ultrasound courses represented the most common method of becoming proficient in POCUS. Overall, the Focused Assessment with Sonography in Trauma scan was the mostly taught application, with 76.3% (274 of 359). Resuscitative, diagnostic, and procedural POCUS were rated as very useful or useful by the most of respondents.The lack of qualified personnel to train (76.9% [447 of 581]), and the insufficient time for physicians to learn, POCUS (63.7% [370 of 581]) were identified as the main limitations to POCUS implementation. The dissemination of pediatric POCUS in the European and Israeli centers we surveyed is limited, and its applications are largely restricted to the Focused Assessment with Sonography in Trauma examination. This is likely related to lack of training programs. In contrast, the potential value of use of POCUS in PEM practice is recognized by the majority of respondents.

Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma.

Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. Diagnostic Tests or Criteria, Level IV.

Are seminal vesicles a potential pitfall during pelvic exploration using point-of-care ultrasound (POCUS)?

BackgroundTrauma is a major cause of death among the working population. Many countries have now adopted a structured approach to trauma management in which ultrasound is used as a primary evaluation tool. While its use has direct therapeutic benefits, many artifacts and pitfalls are inherent to the technique. Knowledge of the most frequently encountered pitfalls in practice could thus help reduce the risk of error and lead to more accurate trauma assessments.ObjectiveThis study evaluates a potential pitfall caused by seminal vesicles during focused assessment with sonography for trauma examinations of the male pelvis performed by an emergency physician with experience in point-of-care ultrasound.MethodsWe took five static and five dynamic (3-s loops) transverse ultrasound images of the pelvis in five healthy males. The images and videos were then incorporated into an online survey and emailed through the World Interactive Network Focused On Critical UltraSound (WINFOCUS) in France and the Ultrasound and Emergency Medicine (UEM) Organization in Belgium. A questionnaire asked anonymous participants to assess the presence of free fluid in the static and dynamic images and to share information about their training and experience in point-of-care ultrasound. To validate the static and dynamic images, the survey was sent to three external radiologists for independent verification.ResultsA total of 191 individuals responded fully or partially to the survey, 114 of whom completed it. Among the 114 participants who completed the survey, the misinterpretation rate was 0.55 (95CI 0.51–0.60) for all static and dynamic ultrasound transverse pelvic views. The misinterpretation rate was 0.61 (95CI 0.55–0.66) and 0.50 (95CI 0.45–0.55) for static and dynamic ultrasound transverse pelvic views, respectively. The three external radiologists answered the questionnaire correctly without misinterpreting the survey ultrasound views.ConclusionsSeminal vesicles are a potential pitfall when interpreting transverse ultrasound images of the male pelvis in the context of point-of-care ultrasound.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians—part I: clinical indications

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort...

Occult Pneumothorax Identification on Extended Focused Assessment with Sonography for Trauma Examination in Children.

Occult pneumothoraces (OPTXs) are defined by air within the pleural space that is not visible on conventional chest radiographs (CXR). The aim of this study was to understand how frequently the Extended Focused Assessment with Sonography for Trauma (eFAST) examination identifies occult PTX in a pediatric blunt trauma population as compared with a criterion standard of chest computed tomography (CCT). This study is a secondary analysis of blunt trauma patients younger than 18 years who underwent CCT at Los Angeles County +USC Medical Center Emergency Department from October 2015 to April 2017. The eFAST examination was performed and documented by an emergency medicine resident with attending oversight or by an emergency medicine attending for each trauma. The eFAST results were reviewed for patients diagnosed with small or trace pneumothoraces identified on CCT. Of 168 pediatric trauma patients undergoing CCT, 16 had OPTXs not seen on CXR and 4 patients had a small/trace PTX without a corresponding CXR performed. None were identified on eFAST. Although the sample size in this data set was small, our eFAST examinations identified none of 16 proven and 4 presumed OPTXs. The standard eFAST examination performed poorly in the detection of OPTXs in this single-center study of pediatric blunt trauma victims.

Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma.

This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables. This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS. A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score. Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.

Role of Point-of-Care Ultrasound in the Early Stages of Trauma Care

Point-of-care ultrasound (POCUS) has been widely adopted in the management of trauma patients by emergency and surgical specialists. Advances in technology, portability, and affordability have contributed to its exponential growth, particularly in the field of trauma anesthesia where ultrasound usage has steadfastly blossomed in recent years. Studies and protocols have expanded beyond the oft-used focused assessment with sonography for trauma examination to include focused cardiac and lung examinations. POCUS may also be useful as an adjunct for airway management, vascular access, and intracranial pressure assessment. There has been a push to incorporate ultrasound use by paramedics and physicians in the pre-hospital trauma setting as well. In this review, we discuss POCUS applications in the early stages of trauma care while emphasizing more recently published literature. This review is targeted toward anesthesia providers who wish to familiarize themselves with evidence-based applications of POCUS in various trauma settings.

Feasibility Evaluation of Commercially Available Video Conferencing Devices to Technically Direct Untrained Nonmedical Personnel to Perform a Rapid Trauma Ultrasound Examination.

Introduction: Point-of-care ultrasound (POCUS) is a rapidly expanding discipline that has proven to be a valuable modality in the hospital setting. Recent evidence has demonstrated the utility of commercially available video conferencing technologies, namely, FaceTime (Apple Inc, Cupertino, CA, USA) and Google Glass (Google Inc, Mountain View, CA, USA), to allow an expert POCUS examiner to remotely guide a novice medical professional. However, few studies have evaluated the ability to use these teleultrasound technologies to guide a nonmedical novice to perform an acute care POCUS examination for cardiac, pulmonary, and abdominal assessments. Additionally, few studies have shown the ability of a POCUS-trained cardiac anesthesiologist to perform the role of an expert instructor. This study sought to evaluate the ability of a POCUS-trained anesthesiologist to remotely guide a nonmedically trained participant to perform an acute care POCUS examination. Methods: A total of 21 nonmedically trained undergraduate students who had no prior ultrasound experience were recruited to perform a three-part ultrasound examination on a standardized patient with the guidance of a remote expert who was a POCUS-trained cardiac anesthesiologist. The examination included the following acute care POCUS topics: (1) cardiac function via parasternal long/short axis views, (2) pneumothorax assessment via pleural sliding exam via anterior lung views, and (3) abdominal free fluid exam via right upper quadrant abdominal view. Each examiner was given a handout with static images of probe placement and actual ultrasound images for the three views. After a brief 8 min tutorial on the teleultrasound technologies, a connection was established with the expert, and they were guided through the acute care POCUS exam. Each view was deemed to be complete when the expert sonographer was satisfied with the obtained image or if the expert sonographer determined that the image could not be obtained after 5 min. Image quality was scored on a previously validated 0 to 4 grading scale. The entire session was recorded, and the image quality was scored during the exam by the remote expert instructor as well as by a separate POCUS-trained, blinded expert anesthesiologist. Results: A total of 21 subjects completed the study. The average total time for the exam was 8.5 min (standard deviation = 4.6). A comparison between the live expert examiner and the blinded postexam reviewer showed a 100% agreement between image interpretations. A review of the exams rated as three or higher demonstrated that 87% of abdominal, 90% of cardiac, and 95% of pulmonary exams achieved this level of image quality. A satisfaction survey of the novice users demonstrated higher ease of following commands for the cardiac and pulmonary exams compared to the abdominal exam. Conclusions: The results from this pilot study demonstrate that nonmedically trained individuals can be guided to complete a relevant ultrasound examination within a short period. Further evaluation of using telemedicine technologies to promote POCUS should be evaluated.

378 Prevalence and Follow-Up of Incidental Findings in Focused Assessment With Sonography for Trauma Examinations

The focused assessment with sonography for trauma (FAST) is a commonly performed point-of-care ultrasound examination to evaluate trauma patients in the emergency department (ED). Incidental findings in imaging studies are a common occurrence with variable clinical significance. Failure to communicate these findings to patients can potentially lead to adverse outcomes and medico legal claims. To our knowledge, no prior study has been performed regarding the frequency and follow-up of incidental findings encountered by emergency physicians on FAST examinations. The objective of this study was to determine the frequency, documentation, and communication of incidental findings on emergency physician-performed FAST ultrasound examinations. This is a retrospective review of FAST examinations performed by emergency physicians for adult trauma patients in two academic EDs. FAST examinations used for medical decision making at the bedside were identified from ED ultrasound image archival system (Q-path). Emergency medicine residents and attending physicians with varied point-of-care ultrasound experience performed and interpreted FAST ultrasound examinations. All identified FAST examinations were reviewed by one of the study investigators for the presence of incidental findings. Additionally, an expert emergency sonologist reviewed all FAST examinations with incidental findings and 10% of FAST examinations with no incidental findings. The patients’ medical records were then reviewed for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings with the patient. Continuous variables were reported as means with standard deviations and categorical variables were reported as proportions. Inter-rater reliability was assessed using the kappa test statistic. A total of 1452 FAST examinations were reviewed over a 15-month period. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had more than one incidental finding. Inter-rater reliability among reviewers was very high (92%). The mean age of patients (78 females, 59 males) with incidental findings was 52 (SD 23); without, 44 (SD 19, p<.001). Motor vehicle collision was the most common mechanism of injury, followed by falls. Renal pathology (cysts and hydronephrosis) was the most common finding (57/137, 41.6%), followed by pelvic cysts in women (40/137, 29.1%). While 31/137 (22.6%) incidental findings were identified and documented in the ultrasound reports by ED providers, only 6/137 (4.4%) patients were informed of their incidental findings. Incidental findings are often encountered in FAST ultrasound examinations, most commonly in older, female patients. A vast majority of incidental findings were not documented and communicated to patients, which may have medico legal implications.

Decreasing Accuracy of the eFAST Examination—Another Challenge Due to Morbid Obesity

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFAST examination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m², the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03-3.32; P = 0.05). For those with BMI > 40 kg/m², the OR increased to OR = 3.12 (95% confidence interval, 1.45-6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.

The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis.

To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side.

During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions. Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups. Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05). Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed. Basic science.

Multimodular Ultrasound Orientation: Residents' Confidence and Skill in Performing Point-of-care Ultrasound.

IntroductionThe objectives of this study were to determine if a multimodular introductory ultrasound course improved emergency medicine intern confidence in performing a point-of-care ultrasound and if our educational objectives could be met with our chosen structure.MethodsThis is a prospective, observational study evaluating three consecutive incoming emergency medicine residency classes from three residency programs. A one-day introductory ultrasound course was delivered. The course consisted of 1) flipped classroom didactics, 2) in-person, case-based interactive teaching sessions, and 3) check-listed, goal-driven, hands-on instruction.ResultsOver three years, 73 residents participated in this study. There was no significant difference in performance on the written test (p = 0.54) or the skills assessment (p = 0.16) between years. Performance on the written pre-test was not a predictor of performance on the skills test (R2 = 0.028; p = 0.19). Prior to training, residents were most confident in performing a focused assessment with sonography for trauma examination (median confidence 5.5 (interquartile range (IQR): 3 - 7) on a 10-point Likert scale where 1 represents low confidence and 10 represents high confidence). They reported the lowest confidence in performing a cardiac ultrasound (3 (IQR: 2 - 6)). Following training, residents reported increased confidence with all applications (p < 0.001). Eighty-five percent (confidence interval (CI): 73, 92) of residents agreed that the online ultrasound lectures effectively teach point-of-care ultrasound applications and 98% (CI: 88, 100) agreed that case-based interactive sessions helped them understand how ultrasound changes the management of acutely ill patients.ConclusionsA written test of knowledge regarding the use of point-of-care ultrasound does not correlate with procedural skills at the start of residency, suggesting that teaching and evaluation of both types of skills are necessary. Following a multimodular introductory ultrasound course, residents showed increased confidence in performing the seven basic ultrasound applications. Residents reported that an asynchronous curriculum and case-based interactive sessions met the learning objectives and effectively taught point-of-care ultrasound applications.

Critical Care Ultrasonography

The use of bedside ultrasonography in the intensive care unit continues to expand due to its broad utility, including diagnosis of various conditions, evaluation of hemodynamics, and improvement in the speed and safety of certain bedside procedures. In this review, the reader will gain a better understanding of the physical properties of ultrasound waves and potential artifacts. The five standard views to perform a basic echocardiographic evaluation are described. This examination provides an adequate assessment of the left ventricle, helping to differentiate acute coronary syndrome, stress cardiomyopathy, and regional or global left ventricular dysfunction. Right ventricular function can be assessed qualitatively or, if desired, quantitatively via measurement of tricuspid annular plane excursion. Echocardiography also allows for assessment of volume status, detection of cardiac tamponade, and signs of hemodynamically significant pulmonary embolism. We also describe bedside ultrasound use for pulmonary assessment and for guidance of thoracentesis. Lung ultrasonography is very sensitive for the detection of pneumothoraces and pleural effusions. The lung parenchyma may also be evaluated by identifying various artifacts such as A-lines and B-lines to delineate underlying pulmonary pathology. Understanding these artifacts allows an experienced practitioner to detect various pathologies such as pneumonia, cardiogenic pulmonary edema, atelectasis, and other conditions. Finally, we discuss abdominal ultrasonography, including the performance of a focused assessment with sonography in trauma examination, performance of a paracentesis, and diagnosis of a pneumoperitoneum. This review contains 11 figures, 1 table, and 53 references. Key words: bedside ultrasonography, echocardiography, focused assessment with sonography in trauma (FAST), focused cardiac ultrasonography (FoCUS), point-of-care ultrasonography