Diagnostic Yield and Accuracy of Bedside Echocardiography in the Emergency Department in Hemodynamically Stable Patients.
Balderston Jessica R,Gertz Zachary M,Brooks Sean,Joyce J Michael,Evans David P
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES:The goal of this study was to determine the diagnostic yield of focused cardiac ultrasound (FOCUS) in hemodynamically stable patients in the emergency department and secondarily to confirm the accuracy of these studies when compared to formal echocardiography. METHODS:All hemodynamically stable adult patients who had an emergency physician-performed FOCUS examination completed over a 1-year period were identified using our electronic ultrasound database. Hemodynamic stability was defined as presenting systolic blood pressure higher than 90 mm Hg and not requiring any form of positive pressure ventilation. RESULTS:There were 1198 FOCUS examinations performed: 976 in hemodynamically stable patients who were included in our analysis. Twenty-seven percent of patients had new findings, including 154 (16%) new diagnoses of reduced left ventricular function, 105 (11%) new pericardial effusions, and 44 (5%) new diagnoses of RV dilatation. Dyspnea as an indication for the FOCUS examination was the strongest predictor of a positive study. Of patients included, 28% underwent formal echocardiography within 2 days and were analyzed for concordance with regard to left ventricular function and the presence of pericardial effusion. Of 270 studies, 208 were accurate, and 62 were inaccurate, for raw agreement of 77% (κ = 0.53). When stratified by sonographer experience, there was no impact on accuracy. CONCLUSIONS:Focused cardiac ultrasound in the emergency department for hemodynamically stable patients revealed new findings in 27% of studies, with a modest correlation with formal echocardiography. In stable patients, FOCUS has the potential for rapid diagnosis of cardiac disease, particularly in patients with dyspnea.
Application of Lung Ultrasound in Critical Care Setting: A Review.
Raheja Ronak,Brahmavar Megha,Joshi Dhruv,Raman Dileep
This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.
The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider.
González Juan M,Ortega Johis,Crenshaw Nichole,de Tantillo Lila
Advanced emergency nursing journal
Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The "FAST" examination-focused assessment with sonography for trauma-ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the "eFAST" (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.
Ultrasound for diagnosing new difficult laryngoscopy indicator: a prospective, self-controlled, assessor blinded, observational study.
Wang Lei,Feng Yan-Kun,Hong Liu,Xie Wan-Li,Chen Shi-Qiang,Yin Ping,Wu Qing-Ping
Chinese medical journal
BACKGROUND:Unpredictable difficult laryngoscopy (DL) remains a challenge for anesthesiologists, especially when difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common airway assessment methods only perform superficial screening. Thus, the deep laryngopharyngeal anatomy may not be evaluated. Ultrasound-based airway assessment has been recently proposed as a useful, simple, and non-invasive bedside tool as an adjunct to clinical methods, which may facilitate identification of DL. The present study aimed to determine the correlation between ultrasound-measured indicators and DL. METHODS:Patients undergoing elective surgery under general anesthesia with tracheal intubation were enrolled. Ultrasonic airway assessments were performed before anesthesia induction. Ultrasound diagnostic indicators included the thickness and width of the base of the tongue, the angle between the epiglottis and glottis, the length of the thyrohyoid membrane, and the thickness of the lateral pharyngeal wall. A score of ≥3 in the Modified Cormack-Lehane Scoring System was used as a standard of DL and was also applied to divide patients into DL and non-DL groups. The area under the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic ability of various diagnostic indicators. RESULTS:A total of 499 patients were enrolled into non-DL and DL groups comprising 452 (452/499, 90.6%) and 47 (47/499, 9.4%) patients, respectively. One ultrasonic diagnoses indicator correlated with DL, namely, the angle between the epiglottis and glottis. When the angle between the epiglottis and glottis was 50°, the area under the ROC curve was maximum (0.902), and the best sensitivity (81%) and specificity (89%) were achieved. CONCLUSIONS:Airway ultrasounds should be considered to identify DL. The ultrasonic angle measured between the epiglottis and glottis is highly associated with DL, which may occur when the angle is less than 50°. CLINICAL TRIAL REGISTRATION:ChiCTR-DDT-13004102, http://www.chictr.org.cn/showproj.aspx?proj=5465.
Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.
Boniface Keith S,Ogle Kat,Aalam Ahmad,LeSaux Maxine,Pyle Matt,Mandoorah Sohaib,Shokoohi Hamid
AEM education and training
OBJECTIVES:Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images. METHODS:In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome. RESULTS:A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans. CONCLUSION:Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.
[Diagnostic value of lung ultrasound B-line score in acute heart failure].
Zhuang Yan,Dai Linfeng,Chen Mingqi,Chang Ning,Chen Jiandong,Shi Haibo
Zhonghua wei zhong bing ji jiu yi xue
OBJECTIVE:To investigate the value of bedside lung ultrasound B-line score in the diagnosis of acute heart failure (AHF). METHODS:A retrospectively analysis was conducted. The adult patients presenting with acute dyspnea in intensive care unit (ICU) of Affiliated Hospital of Nanjing University of Traditional Chinese Medicine from January 2016 to June 2017 were enrolled. An 8-zone lung ultrasound was performed and plasma B-type natriuretic peptide (BNP) level was tested in all patients. AHF was determined as the final diagnosis by two experienced ICU doctors according to the diagnostic criteria of AHF. Patients were divided into two groups: AHF group and non-AHF group. The levels of BNP and B-line score were compared between the two groups, and the diagnostic value of BNP and B-line score in AHF was evaluated. RESULTS:Fifty-six patients were included in this study, with 32 of men and 24 of women, and with an average age of 77.3±8.8. Thirty-six patients were diagnosed as AHF. The level of BNP and lung ultrasound B-line score in AHF group were higher than those in non-AHF group [BNP (ng/L): 1 640.4±1 078.4 vs. 236.9±124.9, B line score: 12.8±5.3 vs. 5.4±1.8, both P < 0.01]. There was a strong correlation between elevated BNP levels and an increased B-lines score (R = 0.712, P = 0.000). The receiver operating characteristic curve (ROC) showed that when the cut-off of lung ultrasound B-line score was 8.5, AHF could be discriminated from dyspnea caused by other diseases (sensitivity was 77.8%, specificity was 95%, positive likelihood ratio was 15.56, negative likelihood ratio was 0.23). The area under the ROC curve (AUC) of lung ultrasound B-line score was 0.917 [95% confidence interval (95%CI) = 0.847-0.987, P = 0.000], slightly lower than that of plasma BNP [0.979 (95%CI = 0.951-1.008)]. CONCLUSIONS:Lung ultrasound B-line score was highly specific, but moderately sensitive for identifying patients with AHF.
[Basic lung ultrasound. Part 1. Normal lung ultrasound and diseases of the chest wall and the pleura].
de la Quintana Gordon F B,Nacarino Alcorta B
Revista espanola de anestesiologia y reanimacion
Lung ultrasound has become part of the diagnostic armamentarium in Resuscitation and Recovery Units with an enormous potential due to its many advantages: capacity to diagnose more precisely than conventional radiology, earlier diagnosis, convenience due to being able to performed at the bedside, possibility of being performed by one person, absence of ionising radiation, and, due to its dynamic character, is capable of transforming into physiological processes that were once static images. However, lung ultrasound also has its limitations and has a learning curve. The aim of this review is to provide sufficient information that may help the specialist starting in this field to approach the technique with good possibilities of success. To do this, the review is structured into two parts. In the first, the normal ultrasound of the chest wall is presented, as well as the pleura, diaphragm, and lung parenchyma, and the most important pathologies of the chest wall (rib fractures and hematomas), the pleura (pleural effusion and its different types, and pneumothorax), and the diaphragm (hypokinesia and paralysis). In the second part, parenchymal diseases will be approached and will include, atelectasis, pneumonia and abscess, lung oedema, respiratory distress, and pulmonary thromboembolism.
Extracardiac Signs of Fluid Overload in the Critically Ill Cardiac Patient: A Focused Evaluation Using Bedside Ultrasound.
Beaubien-Souligny William,Bouchard Josée,Desjardins Georges,Lamarche Yoan,Liszkowski Mark,Robillard Pierre,Denault André
The Canadian journal of cardiology
Fluid balance management is of great importance in the critically ill cardiac patient. Although intravenous fluids are a cornerstone therapy in the management of unstable patients, excessive administration coupled with cardiac dysfunction leads to elevation in central venous pressure and end-organ venous congestion. Fluid overload is known to have a detrimental effect on organ function and is responsible for significant morbidity in critically ill patients. Multisystem bedside point of care ultrasound imaging can be used to assess signs of fluid overload and venous congestion in critically ill patients. In this review we describe the ultrasonographic extracardiac signs of fluid overload and how they can be used to complement clinical evaluation to individualize patient management.
Emergency department ultrasound for the detection of B-lines in the early diagnosis of acute decompensated heart failure: a systematic review and meta-analysis.
McGivery Kyle,Atkinson Paul,Lewis David,Taylor Luke,Harris Tim,Gadd Kathleen,Fraser Jacqueline,Stoica George
OBJECTIVES:Dyspnea is a common presenting problem that creates a diagnostic challenge for physicians in the emergency department (ED). While the differential diagnosis is broad, acute decompensated heart failure (ADHF) is a frequent cause that can be challenging to differentiate from other etiologies. Recent studies have suggested a potential diagnostic role for emergency lung ultrasound (US). The objective of this systematic review was to assess the accuracy of early bedside lung US in patients presenting to the ED with dyspnea. METHODS:A systematic search of EMBASE, PubMed, and the Cochrane Library was performed in addition to a grey literature search. We selected prospective studies that reported on the sensitivity and specificity of B-lines from early lung ultrasound in dyspneic patients presenting to the ED. Selected studies underwent quality assessment using the Critical Appraisal and Skills Program (CASP) questionnaire. DATA EXTRACTION AND SYNTHESIS:The search yielded 3674 articles; seven studies met inclusion criteria and fulfilled CASP requirements for a total of 1861 patients. Summary statistics from the meta-analysis showed that as a diagnostic test for ADHF, bedside lung US had a pooled sensitivity of 82.5% (95% confidence interval [CI]=66.4% to 91.8%) and a pooled specificity of 83.6% (95% CI=72.4% to 90.8%). CONCLUSIONS:Our results suggest that in patients presenting to the ED with undifferentiated dyspnea, B-lines from early bedside lung US may be reliably used as an adjunct to current diagnostic methods. The incorporation of lung US may lead to more appropriate and timely diagnosis of patients with undifferentiated ADHF.
A plea for an early ultrasound-clinical integrated approach in patients with acute heart failure. A proactive comment on the ESC Guidelines on Heart Failure 2016.
Tavazzi G,Neskovic A N,Hussain A,Volpicelli G,Via G
International journal of cardiology
BACKGROUND:The European Association of Cardiology (ESC) Guidelines on the diagnosis and treatment of acute heart failure (AHF) indicate prompt therapy initiation and performance of relevant investigations as paramount. Specifically, echocardiography prior to treatment is advocated only with hemodynamic instability, and the evaluation of clinical signs of peripheral perfusion and congestion is suggested as guidance for early interventions. Given the growing body of evidence on the diagnostic/monitoring capabilities of bedside ultrasound (including focused cardiac ultrasound, comprehensive echocardiography, lung ultrasound), we discuss the potential benefit of an integrated clinical/ultrasound approach at the very early stages of acute heart failure. METHODS AND RESULTS:We proposed a narrative review of the current evidence on the clinical-ultrasound integrated approach to AHF, with special emphasis on the components of the early diagnostic-therapeutic workup where cardiac, inferior vena cava and lung ultrasound showed high diagnostic accuracy and the capability of substantially changing an exclusively clinically-oriented patient management. A proactive comment to the ESC guidelines is made, suggesting an integration of clinical and biochemical assessment, as defined by guidelines, with combined bedside ultrasound on may help in the definition of AHF pathophysiology and treatment. CONCLUSION:A multi-organ integrated clinical-ultrasound approach should be advocated as part of the clinical-diagnostic workup at AHF very early phase. Whenever competence and technology available, bedside ultrasound, along with clinical and biochemical assessment, should target AHF profiling, identify the cause of AHF, and subsequently aid disease course and response to treatment monitoring.
Bedside cardiac ultrasound training should be mandated in the emergency department.
Australasian journal of ultrasound in medicine
BACKGROUND:Bedside cardiac ultrasound can be performed quickly and accurately in the emergency department to diagnose and treat cardiovascular causes of patient deterioration. In Australian emergency departments, it is an underutilised tool. This may be because becoming proficient at performing bedside cardiac ultrasound is not mandated by the Australasian College for Emergency Medicine. CASES:Case 1: A 45-year-old male presented with hypoxia and shock and head injury. Findings consistent with pulmonary embolism on bedside cardiac ultrasound prompted rapid treatment with thrombolysis. The patient survived to hospital discharge.Case 2: A 54-year-old female presented with chest pain. Her bedside cardiac ultrasound revealed a dilated proximal aorta and a dissection flap in the abdominal aorta enabling investigations and operative management to be expedited.Case 3: A 21-year-old male presented with features of lower respiratory tract infection. Chest X-ray revealed a large heart and consolidation. Bedside cardiac ultrasound demonstrated severe dilated cardiomyopathy and prompted the patient's admission into the coronary care unit. CONCLUSION:Evidence shows that emergency doctors can perform bedside cardiac ultrasound accurately after minimal training. It increases the accuracy of diagnosis. Training in this vital diagnostic tool should be mandated for emergency medicine trainees in Australia.
Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.
Stolz Lori A,Stolz Uwe,Fields J Matthew,Saul Turandot,Secko Michael,Flannigan Matthew J,Sheele Johnathan M,Rifenburg Robert P,Weekes Anthony J,Josephson Elaine B,Bedolla John,Resop Dana M,Dela Cruz Jonathan,Boysen-Osborn Megan,Caffery Terrell,Derr Charlotte,Bengiamin Rimon,Chiricolo Gerardo,Backlund Brandon,Heer Jagdipak,Hyde Robert J,Adhikari Srikar
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
OBJECTIVES:Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS:This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS:There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS:EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.
Diagnostic value of cardiopulmonary ultrasound in elderly patients with acute respiratory distress syndrome.
Huang Daozheng,Ma Huan,Xiao Zhiyuan,Blaivas Michael,Chen Ying,Wen Jianyi,Guo Weixin,Liang Jun,Liao Xiaolong,Wang Zhonghua,Li Hanbiao,Li Jie,Chao Yangong,Wang Xiao Ting,Wu Yan,Qin Tiehe,Su Ke,Wang Shouhong,Tan Ning
BMC pulmonary medicine
BACKGROUND:Lung ultrasound and echocardiography are mainly applied in critical care and emergency medicine. However, the diagnostic value of cardiopulmonary ultrasound in elderly patients with acute respiratory distress syndrome (ARDS) is still unclear. METHODS:Consecutive patients admitted to ICU with the diagnosis of suspected ARDS based on clinical grounds were enrolled. Cardiopulmonary ultrasound was performed as part of monitoring on day 1, day 2 and day 3. On each day a bedside ultrasound was performed to examine the lungs and calculate the Left Ventricular Ejection Fraction (LVEF). On day 3, a thoracic CT was performed on each patient as gold standard for ARDS imaging diagnosis. According to the results from CT scan, patients were grouped into ARDS group or Non-ARDS group. The relation between the cardiopulmonary ultrasound results on each day and the results of CT scan was analyzed. RESULTS:Fifty one consecutive patients aged from 73 to 97 years old were enrolled. Based on CT criteria, 33 patients were classified into the ARDS group, while 18 patients were included in non-ARDS group. There was no significant difference between the two groups in baseline characteristics, including gender, age, underlying disease, comorbidities, APACHE II score, SOFA score, and PaO2/FiO2 ratio (P > 0.05). Lung ultrasound (LUS) examination results were consistent with the CT scan results in diagnosis of pulmonary lesions. The Kappa values were 0.55, 0.74 and 0.82 on day 1, day 2 and day 3, respectively. The ROC analysis showed that the sensitivity, specificity and area under curve of ROC (AUROC) for lung ultrasound in diagnose ARDS were 0.788,0.778,0.783;0.909,0.833,0.871;0.970,0.833,0.902 on day 1, day 2 and day 3, respectively. However, cardiopulmonary ultrasound performed better in diagnosing ARDS in elderly patients. The sensitivity, specificity and AUROC were 0.879,0.889,0.924;0.939,0.889,0.961;and 0.970,0.833,0.956 on day 1, day 2 and day 3, respectively. The combined performances of cardiopulmonary ultrasound, N-terminal pro-brain natriuretic peptide (NT-proBNP), and PaO2/FiO2 ratio improved the specificity of the diagnosis of ARDS in elderly patients. CONCLUSIONS:LUS examination results were consistent with the CT scan results in diagnosis of pulmonary lesions. Cardiopulmonary ultrasound has a greater diagnostic accuracy in elderly patients with ARDS, compared with LUS alone. The combined performances of cardiopulmonary ultrasound, NT-proBNP, and PaO/FiO increased the specificity of the diagnosis of ARDS in elderly patients.
Bedside Lung Ultrasound for Postoperative Lung Conditions in Cardiothoracic Intensive Care Unit: Diagnostic Value and Comparison with Bedside Chest Roentgenogram.
Anesthesia, essays and researches
BACKGROUND:The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions. AIMS AND OBJECTIVES:Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs. MATERIALS AND METHODS:Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test. RESULTS:CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931). CONCLUSIONS:LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.
Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department.
Gungor Faruk,Kilic Taylan,Akyol Kamil Can,Ayaz Gizem,Cakir Umut Cengiz,Akcimen Mehmet,Eken Cenker
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
OBJECTIVE:Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED). METHODS:The study sample consisted of patients aged > 18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared. RESULTS:A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000). CONCLUSION:Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.
Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study.
Hasani Seyyed Abbas,Fathi Marzieh,Daadpey Marzieh,Zare Mohammad Amin,Tavakoli Nader,Abbasi Saeed
OBJECTIVE:Abdominal pain is a common complaint in the emergency department and accurate diagnosis of its etiology may affect the patient's outcome. METHOD:Patients with abdominal pain underwent ultrasound study first by trained emergency physicians and then by radiologists blinded to emergency physician's results. RESULT:Emergency physician who performed bedside ultrasound had 78% diagnostic accuracy. Emergency physicians showed better results in diagnosing some entities (abdominal aortic aneurysm and renal stones) than the others (acute appendicitis, cholelithiasis, and cholecystitis). CONCLUSION:Bedside ultrasound can accurately identify the etiology of acute nontraumatic abdominal pain in the hands of emergency physicians.
Clinician-Performed Bedside Ultrasound in Improving Diagnostic Accuracy in Patients Presenting to the ED with Acute Dyspnea.
Papanagnou Dimitrios,Secko Michael,Gullett John,Stone Michael,Zehtabchi Shahriar
The western journal of emergency medicine
INTRODUCTION:Diagnosing acute dyspnea is a critical action performed by emergency physicians (EP). It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. We sought to examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of EPs evaluating dyspneic patients, and to measure the change in physician confidence with the leading diagnosis before and after US. METHODS:We conducted a prospective observational study of EPs treating adult patients with undifferentiated dyspnea in an urban academic center, excluding those with a known cause of dyspnea after evaluation. Outcomes: 1) percentage of post-US diagnosis matching final diagnosis; 2) percentage of time US changed providers' leading diagnosis; and 3) change in physicians' confidence with the leading diagnosis before and after US. An US protocol was developed and standardized prior to the study. Providers (senior residents, fellows, attendings) were trained on US (didactics, hands on) prior to enrollment, and were supervised by an US faculty member. After patient evaluation, providers listed likely diagnoses, documenting their confidence level with their leading diagnosis (scale of 1-10). After US, providers revised their lists and their reported confidence level with their leading diagnosis. Proportions are reported as percentages with 95% confidence interval (CI) and continuous variables as medians with quartiles. We used the Wilcoxon signed-rank test and Cohen's kappa statistics to analyze data. RESULTS:A total of 115 patients were enrolled (median age: 61 [51, 73], 59% female). The most common diagnosis before US was congestive heart failure (CHF) (41%, 95%CI, 32-50%), followed by chronic obstructive pulmonary disease (COPD) and asthma. CHF remained the most common diagnosis after US (46%, 95%CI, 38-55); COPD became less common (pre-US, 22%, 95%CI, 15-30%; post-US, 17%, 95%CI, 11-24%). Post-US clinical diagnosis matched the final diagnosis 63% of the time (95%CI, 53-70%), compared to 69% pre-US (95%CI, 60-76%). Fifty percent of providers changed their leading diagnosis after US (95%CI, 41-59%). Overall confidence of providers' leading diagnosis increased after US (7 [6, 8]) vs. 9 [8, 9], p: 0.001). CONCLUSION:Bedside US did not improve the diagnostic accuracy in physicians treating patients presenting with acute undifferentiated dyspnea. US, however, did improve providers' confidence with their leading diagnosis.
Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients.
Dexheimer Neto Felippe Leopoldo,Andrade Juliana Mara Stormovski de,Raupp Ana Carolina Tabajara,Townsend Raquel da Silva,Beltrami Fabiana Gabe,Brisson Hélène,Lu Qin,Dalcin Paulo de Tarso Roth
Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia
OBJECTIVE:Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. METHODS:Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). RESULTS:Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. CONCLUSIONS:LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.
[The clinical value of bedside lung ultrasound in the diagnosis of chronic obstructive pulmonary disease and cardiac pulmonary edema].
Zhou Shusheng,Zha Yu,Wang Chunyan,Wu Junfan,Liu Weiyong,Liu Bao
Zhonghua wei zhong bing ji jiu yi xue
OBJECTIVE:To study the diagnostic accuracy of bedside lung ultrasound examination in chronic obstructive pulmonary disease (COPD) and cardiac pulmonary edema. METHODS:A prospective pilot and single-blind trial was conducted. A total of 89 patients with respiratory failure admitted to the Department of Critical Care Medicine of Anhui Provincial Hospital from September 2012 to September 2013 were enrolled. There were 32 patients with COPD, 31 patients with cardiac pulmonary edema, 8 patients with interstitial lung disease, 12 with lung infection, and 6 patients with other diseases. Another group of 30 patients without respiratory disease were enrolled as the control group. Bedside lung ultrasound examinations were performed in all patients within 24 hours, and chest radiograph was performed at the same time. The signs to be revealed were the "A" lines or horizontal lines arising from the pleural line, and the comet-tail artifact ("B" lines) arising from the lung wall interface. RESULTS:Of 89 patients, 33 patients were shown a mean of 2.94 ± 1.87 "A" lines per case with the bedside lung ultrasound, and 38 patients with a mean of 3.27 ± 1.72 "B" lines per patient. 1.94 ± 0.96 "A" lines a case and 1.74 ± 0.82 "B" lines a case in control group. There were significant difference between the test group and control group ("A"line: t=3.835, P=0.000; "B" line: t=6.540, P=0.000). Among 32 cases with COPD, 28 patients had a positive result of "A" line with a coincidence rate of 81.2%. In the 31 patients with cardiac pulmonary edema, 25 patients presented "B" line, with a coincidence rate of 80.6%. The "A" lines or horizontal lines arising from the pleural line showed a sensitivity of 81.30% and a specificity of 87.70% with a positive predictive value (PPV) 78.80% and a negative predictive value (NPV) 89.30% of in the diagnosis of COPD, and the "B" lines showed a sensitivity of 80.60% and a specificity of 77.60% with a PPV of 65.80% and a NPV of 88.20% in the diagnosis of cardiac pulmonary edema. However, X-ray examination showed a sensitivity of 65.50%, a specificity of 86.00%, a PPV of 72.40% and a NPV of 81.70% in the diagnosis of COPD, and it showed a sensitivity of 74.20%, a specificity of 69.00%, a PPV of 56.10% and a NPV of 83.30% in the diagnosis of cardiac pulmonary edema. Bedside ultrasound was highly consistent with X-ray in diagnosis of COPD [area under receiver operating characteristic curve (AUC): 0.833 vs. 0.816, P>0.05], but Kappa value of ultrasound technology "A" line in the diagnosis of COPD was greater than the value of X-ray imaging techniques (0.685 vs. 0.527). There was little diagnostic value of ultrasound "A" line in cardiac pulmonary edema(AUC was 0.305), while the "B" line was superior to X-ray (AUC: 0.888 vs. 0.747, P<0.001), and had a higher Kappa value than the value of X-ray imaging techniques (0.553 vs. 0.481) in cardiac pulmonary edema. CONCLUSIONS:We conclude that bedside ultrasound is cost-effective, easy for repeated examination, and suitable for differential diagnosis of lung diseases. It might be useful in screening for COPD and cardiac pulmonary edema.
Evaluating and assessing the prevalence of bedside ultrasound in emergency departments in China.
Shi Di,Walline Joseph H,Yu Xuezhong,Xu Jun,Song Priscilla P,Zhu Huadong
Journal of thoracic disease
BACKGROUND:To survey the prevalence of bedside ultrasound assessment in emergency departments (EDs) in China. METHODS:We designed an online survey for emergency physicians based in the China. The questionnaire included sixteen items querying common ED bedside ultrasound practices. Respondents were recruited via weblinks sent through social media and a popular Chinese emergency medicine website. Survey data was collected from April through June, 2016. RESULTS:Four hundred and twenty-eight physicians responded to this survey; more than 80% of respondents reported working clinically in the ED. Ninety-eight percent of respondents agreed on the clinical importance and value of bedside ultrasound. However, less than half of participants' EDs had ultrasound devices, and less than half of the respondents said they knew how to perform bedside ultrasound. Less than 20% of respondents reported having had formal training in bedside ultrasound. CONCLUSIONS:There is a strong interest in bedside ultrasound in Chinese EDs. Emergency physicians participating in this study considered bedside ultrasound a necessary skill, but, because there is a lack of training, most emergency physicians reported they did not know how to perform bedside ultrasonography. There is likely an acute desire and need for bedside ultrasound training for Chinese emergency physicians.
Evaluation of a Short-term Training Program in Bedside Emergency Ultrasound in Southwestern Tanzania.
Shaffer Mark,Brown Heather A,McCoy Chloé,Bashaka Prosper
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES:To evaluate the effect of a short-term training program in emergency ultrasound on physician skills and attitudes in southwestern Tanzania. METHODS:Eight registrar physicians at Mbeya Zonal Referral Hospital (Mbeya, Tanzania) underwent a 5-day course in bedside emergency ultrasound, focusing primarily on the focused assessment with sonography for trauma examination, including didactic sessions, practical sessions, and on-job training. The impact on ultrasound knowledge was assessed by pretest and posttest evaluations. Provider skill was evaluated by a standardized observed simulated patient encounter. Attitudes toward ultrasound training, utility, and self-confidence were assessed by a post-training questionnaire. RESULTS:All 8 physicians who began the training completed the course and successfully passed their objective structured clinical examination. There was a statistically significant improvement in written ultrasound test scores from 31% to 66% (P < .01) after the course. Most trainees felt confident performing and interpreting a basic focused assessment with sonography for trauma examination at the end of the course, and 7 of 8 stated that they would consider paying tuition for similar courses in the future. Main concerns with the course revolved around insufficient time dedicated to practicing under supervision. CONCLUSIONS:Registrar physicians in Tanzania can effectively learn basic emergency ultrasound skills in a short-term training program. Similar future programs may consider heavier emphasis on practical hands-on training with experts. Ongoing data collection is required to understand the true impact of such training on long-term ultrasound use and patient outcomes.
Evaluation of the Diagnostic Role of Bedside Lung Ultrasonography in Patients with Suspected Pulmonary Embolism in the Emergency Department.
Acar Hüseyin,Yılmaz Serkan,Yaka Elif,Doğan Nurettin Özgür,Özbek Asım Enes,Pekdemir Murat
Balkan medical journal
BACKGROUND:Despite the existence of detailed consensus guidelines, challenges remain regarding efficient, appropriate, and safe imaging methods for the diagnosis of suspected pulmonary embolism. AIMS:To investigate the role of the wedge sign, B-lines, and pleural effusion seen on bedside lung ultrasound in the diagnosis of pulmonary embolism. STUDY DESIGN:Diagnostic accuracy study. METHODS:During the first evaluation of patients with suspected pulmonary embolism, bedside lung ultrasound was performed, and the B-lines, wedge sign, and pleural effusion were investigated. Computed tomography angiography was used as a confirmatory test and was compared with the lung ultrasound findings. RESULTS:Pulmonary embolism was detected in 38 (38%) patients. In the comparison of bedside lung ultrasound results, statistically significant differences were found between the groups in terms of the B-lines and wedge sign (p=0.005 and p>0.001, respectively). There were no significant differences in terms of effusion (p=0.234). Comparison of these findings with computed tomography angiography of the chest showed weak negative correlations between the groups in terms of B-lines (r=-0297) and a moderately positive correlation in terms of the wedge sign (r=0.523). The sensitivity, specificity, and positive and negative predictive values of lung ultrasound findings alone were low. In the logistic regression analysis, the wedge sign (p>0.01, OR=69.45, 95% CI=6.94-695.17) and B-line (p=0.033, OR=1.96, 95% CI=0.41-8.40) were found to be effective in the diagnosis of pulmonary embolism. CONCLUSION:Although the role of lung ultrasound has been increasing in the management of critically ill patients, its value is limited and cannot replace the gold standard tests in the diagnosis of pulmonary embolism.
[Lung ultrasound in acute and critical care medicine].
Zechner P M,Seibel A,Aichinger G,Steigerwald M,Dorr K,Scheiermann P,Schellhaas S,Cuca C,Breitkreutz R,
The development of modern critical care lung ultrasound is based on the classical representation of anatomical structures and the need for the assessment of specific sonography artefacts and phenomena. The air and fluid content of the lungs is interpreted using few typical artefacts and phenomena, with which the most important differential diagnoses can be made. According to a recent international consensus conference these include lung sliding, lung pulse, B-lines, lung point, reverberation artefacts, subpleural consolidations and intrapleural fluid collections. An increased number of B-lines is an unspecific sign for an increased quantity of fluid in the lungs resembling interstitial syndromes, for example in the case of cardiogenic pulmonary edema or lung contusion. In the diagnosis of interstitial syndromes lung ultrasound provides higher diagnostic accuracy (95%) than auscultation (55%) and chest radiography (72%). Diagnosis of pneumonia and pulmonary embolism can be achieved at the bedside by evaluating subpleural lung consolidations. Detection of lung sliding can help to detect asymmetrical ventilation and allows the exclusion of a pneumothorax. Ultrasound-based diagnosis of pneumothorax is superior to supine anterior chest radiography: for ultrasound the sensitivity is 92-100% and the specificity 91-100%. For the diagnosis of pneumothorax a simple algorithm was therefore designed: in the presence of lung sliding, lung pulse or B-lines, pneumothorax can be ruled out, in contrast a positive lung point is a highly specific sign of the presence of pneumothorax. Furthermore, lung ultrasound allows not only diagnosis of pleural effusion with significantly higher sensitivity than chest x-ray but also visual control in ultrasound-guided thoracocentesis.
Update on bedside ultrasound diagnosis of pericardial effusion.
Ceriani Elisa,Cogliati Chiara
Internal and emergency medicine
Pericardial effusion (PE) is the presence of an excess of fluid in the pericardial cavity. PE symptoms depend from the rate of fluid accumulation, ranging from mild dyspnea on exertion to shock due to cardiac tamponade. Echocardiography is usually the primary diagnostic tool when PE is suspected, as it is accurate, non-invasive, widely available, and feasible also with pocket size devices. Studies have shown a high degree of sensitivity and specificity in the detection of PE using focused cardiac ultrasound (FOCUS), which can be performed also by non-cardiologist in emergency setting or at bedside. A PE is visualized as an echo-free space between the heart and the parietal layer of the pericardium. A semi-quantification of the PE may be obtained measuring the distance between the two pericardial layers. Once PE diagnosis has been made, characterization of fluid and search for signs of possible cardiac tamponade have to be performed. While unechogenic space is usually associated with serous fluid, hemorrhagic, and purulent effusions may be suspected in the presence of corpuscolated/echogenic fluid. Echocardiography may identify cardiac tamponade before it is clinically evident, and can guide pericardiocentesis. B-mode echocardiographic signs of cardiac tamponade include cardiac chambers collapse (with right chambers collapse occurring at earlier stages), opposite changes in right and left cardiac chamber filling during respiratory cycle, inferior vena cava and hepatic vein plethora. Doppler analysis of tricuspidalic and mitral flow velocities are used for a more detailed analysis of ventricular interdependence, even though more advanced operator expertise is required.
Diagnostic point-of-care ultrasound: assessment techniques for the pediatric trauma patient
Guttman Joshua,Nelson Bret P.
Pediatric emergency medicine practice
Emergency ultrasound is performed at the point of care to quickly answer focused clinical questions. Over the last 25 years, the use of this technique has expanded rapidly. The use of emergency ultrasound in the pediatric setting is increasing because it does not expose the patient to ionizing radiation, as compared to computed tomography. Utilizing diagnostic point-of-care ultrasound for pediatric trauma patients in the emergency department can facilitate diagnosis at the bedside rather than sending the patient out of the department for another study. This supplement focuses on some of the common indications for diagnostic POCUS that may be useful in the setting of trauma, as found in the pediatric literature, or extrapolated from adult literature where pediatric evidence is scarce.
Cardiac and vascular point-of-care ultrasound: current situation, problems, and future prospects.
Yamada Hirotsugu,Ito Hiroyuki,Fujiwara Mika
Journal of medical ultrasonics (2001)
Although clinical application of ultrasound to the heart has a history of about 80 years, its big turning point was the emergence of a portable ultrasound diagnostic machine. As a result, the place, where echocardiography is performed widely spread outside the examination room, and the people who perform echocardiography have also greatly increased. Emergency physicians, anesthesiologists, and primary care physicians became interested in echocardiography and started using it. Such ultrasound examinations performed by a doctor for assessment of disease condition, management, or guidance of treatment at bedside has been called point-of-care ultrasound (POCUS). Cardiac POCUS is divided into a focused cardiac ultrasound examination (FoCUS) and limited echocardiography. The former is performed by non-experts in echocardiography, such as emergency physicians and anesthesiologists, whereas the latter is usually performed by cardiologists who are experts in echocardiography. FoCUS has an established protocol and evaluation method, and evidence to prove its effectiveness is accumulating. In addition, the COVID-19 outbreak reaffirmed the importance of POCUS. Although FoCUS is becoming popular in Japan, an educational program has not been established, and discussion on how to educate medical students and residents will be necessary. Even if POCUS in cardiovascular medicine becomes widespread, auscultation will still be necessary. Rather, adding cardiac and vascular POCUS to inspection, palpation, and auscultation in the flow of physical examinations will benefit patients greatly.
Pulmonary Ultrasound: A New Era in Critical Care Medicine.
Ñamendys-Silva Silvio A,Garrido-Aguirre Eduardo,Romero-González Juan P,Mena-Arceo Roger G,Rojo Del Moral Oscar,González-Chon Octavio
Pulmonary ultrasonography is a complementary study that is easy to perform at the patient bedside with no need to transfer the patient to special areas. The technique provides information with high sensitivity and specificity for different pathologies. Pulmonary ultrasonography is a very important diagnostic tool in the assessment of lung, pleural, and chest wall diseases. Pulmonary ultrasound provides low-cost analysis, easy real-time reproduction, and safety, all of which have made it a beneficial tool in the diagnostic arsenal available to medical personnel. The purpose of this review was to describe the usefulness of pulmonary ultrasound in critical areas.
Lung Ultrasound Scanning for Respiratory Failure in Acutely Ill Patients: A Review.
Koenig Seth,Mayo Paul,Volpicelli Giovanni,Millington Scott J
Lung ultrasonography (LUS), an imaging modality quickly performed, interpreted, and integrated by the treating physician at the bedside, is a particularly useful tool for acutely ill patients. In the evaluation of a patient with respiratory failure in the ICU or ED, LUS is superior to chest radiograph and generally comparable with CT imaging and reduces the need for patient transport and radiation exposure. This article will provide a concise review of LUS as it pertains to respiratory failure in general and will include examples of relevant ultrasound images and video clips from critically ill patients.
Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications.
Raimondi Francesco,Yousef Nadya,Migliaro Fiorella,Capasso Letizia,De Luca Daniele
Lung ultrasound (LUS) is the latest amongst imaging techniques: it is a radiation-free, inexpensive, point-of-care tool that the clinician can use at the bedside. This review summarises the rapidly growing scientific evidence on LUS in neonatology, dividing it into descriptive and functional applications. We report the description of the main ultrasound features of neonatal respiratory disorders and functional applications of LUS aiming to help a clinical decision (such as surfactant administration, chest drainage etc). Amongst the functional applications, we propose SAFE (Sonographic Algorithm for liFe threatening Emergencies) as a standardised protocol for emergency functional LUS in critical neonates. SAFE has been funded by a specific grant issued by the European Society for Paediatric Research. Future potential development of LUS in neonatology might be linked to its quantitative evaluation: we also discuss available data and research directions using computer-aided diagnostic techniques. Finally, tools and opportunities to teach LUS and expand the research network are briefly presented.
Cardiovascular examination using hand-held cardiac ultrasound.
Jenkins Sam,Shiha Mohamed G,Yones Eron,Wardley James,Ryding Alisdair,Sawh Chris,Flather Marcus,Morris Paul,Swift Andrew J,Vassiliou Vassilios S,Garg Pankaj
Journal of echocardiography
Echocardiography is the first-line imaging modality for assessing cardiac function and morphology. The miniaturisation of ultrasound technology has led to the development of hand-held cardiac ultrasound (HCU) devices. The increasing sophistication of available HCU devices enables clinicians to more comprehensively examine patients at the bedside. HCU can augment clinical exam findings by offering a rapid screening assessment of cardiac dysfunction in both the Emergency Department and in cardiology clinics. Possible implications of implementing HCU into clinical practice are discussed in this review paper.
Emergency bedside ultrasound-benefits as well as caution: Part 2: Echocardiography.
Godement Mathieu,Malbrain Manu L N G,Vieillard-Baron Antoine
Current opinion in critical care
PURPOSE OF REVIEW:Critical care echocardiography (CCE) has become an important component of general critical care ultrasonography, and a current review of its performance is presented. RECENT FINDINGS:Basic CCE should be performed as a goal-directed examination to better identify specific signs and to answer important clinical questions concerning acute hemodynamic concerns. It has evolved in the ICU and also in the emergency department not only for improved diagnostic capability but also as an effective part of the triage process. It remains an efficacious procedure even in patients with respiratory failure when combined with lung ultrasonography. Numerous acronyms were proposed, but in all cases, CCE responds to the same rules as fundamental echocardiography. Basic CCE requires accessible and comprehensive training for physicians and is mandatory for all intensivists. Development of pocket echo devices may increase the use of basic CCE as has miniaturization of other medical technologies. Performance should be managed by guidelines, and the CCE training program should be standardized worldwide. More trials are welcome to evaluate its impact on patient outcomes. SUMMARY:Thanks to its ability to quickly obtain a diagnostic orientation at the bedside and to implement targeted therapy, basic CCE over the past decade has become an essential tool for hemodynamic assessment of the cardiopulmonary unstable patient. Its more recent incorporation into the education of trainees in medical school and residencies/fellowships has reinforced its perceived importance in critical care management, despite the relative paucity as yet of rigorous scientific evidence demonstrating positive outcome modification from its use.
Emergency bedside ultrasound: benefits as well as caution - part 1. General.
Wong Adrian,Vieillard-Baron Antoine,Malbrain Manu L N G
Current opinion in critical care
PURPOSE OF REVIEW: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. RECENT FINDINGS: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. SUMMARY: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.
Point-of-Care Ultrasound in Trauma.
Gleeson Timothy,Blehar David
Seminars in ultrasound, CT, and MR
The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.
Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine?
Smallwood Nicholas,Dachsel Martin
Clinical medicine (London, England)
Over the last decade there has been increasing interest and enthusiasm in point-of-care ultrasound (POCUS) as an aide to traditional examination techniques in assessing acutely unwell adult patients. However, it currently remains the domain of a relatively small handful of physicians within the UK. There are numerous reasons for this, notably a lack of training pathways and supervisors but also a lack of understanding of the evidence base behind this imaging modality. This review article aims to explore some of the evidence base behind POCUS for a number of medical pathologies, and where possible compare it to evidenced traditional examination techniques. We discuss the issues around training in bedside ultrasound and recommend a push to integrate POCUS training into internal medicine curricula and support trainers to comprehensively deliver this.
Lung ultrasound in the critically ill.
Current opinion in critical care
PURPOSE OF REVIEW:Lung ultrasound, which allows a bedside visualization of the lungs, is increasingly used in critical care. This review aims at highlighting a simple approach to this new discipline. RECENT FINDINGS:The 10 basic signs are the bat sign (indicating pleural line), lung sliding (yielding the seashore sign), the A line (horizontal artifact), the quad and sinusoid sign indicating pleural effusion regardless of its echogenicity, the tissue-like and shred sign indicating lung consolidation, the B line and lung rockets (artifacts indicating interstitial syndrome), abolished lung sliding with the stratosphere sign, suggesting pneumothorax, and the lung point, indicating pneumothorax. All these disorders were assessed using computed tomography (CT) as a gold standard with sensitivity and specificity ranging from 90 to 100%, allowing us to consider ultrasound as a reasonable bedside gold standard in the critically ill. We use a simple gray-scale unit (without Doppler) with a microconvex probe. SUMMARY:Lung ultrasound can be used for diagnosing acute respiratory failure (BLUE protocol), managing acute circulatory failure (Fluid Administration Limited by Lung Sonography protocol), and decreasing the use of radiograph or CT (the Lung Ultrasound in the Critically Ill Favoring Limitation of Radiation project). This can be extended from sophisticated ICUs to more austere settings, from neonates to bariatric adults without adaptation, trauma and several other disciplines (anesthesiology, emergency medicine, pulmonology, etc.). VIDEO ABSTRACT:http://links.lww.com/COCC/A8.
A practical guide to the lung ultrasound for the assessment of congestive heart failure.
Iwakura Katsuomi,Onishi Toshinari
Journal of echocardiography
Dyspnea is one of the major symptoms encountered in the emergency department, and lung ultrasound (LUS) is recommended for the rapid diagnosis of the underlying disease. B-lines, the "comet-tail"-like vertical lines moving with respiration, are an ultrasound finding relevant to the pulmonary congestion. They may be observed in the normal lung, but bilateral, ≥ 3 B-lines are considered pathological. B-lines with lung sliding (B profile) are a specific sign of heart failure, while B-lines with abolished lung sliding (B' profile) are related with the lung diseases such as acute respiratory distress syndrome. B profile is reported to detect pulmonary edema with about 95% sensitivity and 95% specificity in patients with dyspnea. LUS also can assess the severity of pulmonary congestion semi-quantitatively by counting the number of B-lines or that of positive areas. Whereas the original BLUE protocol requires scanning at 12 zones on the chest, more rapid 8- or 6-zone scan is sufficient for the diagnosis of heart failure, and 2- or 4-zone scan may be used for the critical patients. LUS may be used for the evaluation of heart failure treatment, or can be performed as a part of exercise stress test. LUS can be performed easily and rapidly at the bedside using almost any kind of ultrasound apparatus, and it should be performed more widely in the daily practice as well as in the emergent department.
Lung Ultrasound for Critically Ill Patients.
Mojoli Francesco,Bouhemad Bélaid,Mongodi Silvia,Lichtenstein Daniel
American journal of respiratory and critical care medicine
Point-of-care ultrasound is increasingly used at the bedside to integrate the clinical assessment of the critically ill; in particular, lung ultrasound has greatly developed in the last decade. This review describes basic lung ultrasound signs and focuses on their applications in critical care. Lung semiotics are composed of artifacts (derived by air/tissue interface) and real images (i.e., effusions and consolidations), both providing significant information to identify the main acute respiratory disorders. Lung ultrasound signs, either alone or combined with other point-of-care ultrasound techniques, are helpful in the diagnostic approach to patients with acute respiratory failure, circulatory shock, or cardiac arrest. Moreover, a semiquantification of lung aeration can be performed at the bedside and used in mechanically ventilated patients to guide positive end-expiratory pressure setting, assess the efficacy of treatments, monitor the evolution of the respiratory disorder, and help the weaning process. Finally, lung ultrasound can be used for early detection and management of respiratory complications under mechanical ventilation, such as pneumothorax, ventilator-associated pneumonia, atelectasis, and pleural effusions. Lung ultrasound is a useful diagnostic and monitoring tool that might in the near future become part of the basic knowledge of physicians caring for the critically ill patient.
Bedside ultrasound in cardiac standstill: a clinical review.
Hussein Laila,Rehman Mohammad Anzal,Sajid Ruhina,Annajjar Firas,Al-Janabi Tarik
The ultrasound journal
Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the 'crashed' patient. However, management during resuscitation often encourages a 'one-size-fits-all' policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.
Use of bedside ultrasound to assess fluid status: a literature review.
Piotrkowski Jakub,Buda Natalia,Januszko-Giergielewicz Beata,Kosiak Wojciech
Polish archives of internal medicine
The assessment of a patient's body fluid status is a challenging task for modern clinicians. Ultrasonography has numerous advantages, the most important being reproducibility and bedside monitoring of the patient. The examination is quick and has a significant diagnostic value. We reviewed the literature to assess the possibility of using ultrasound methods for evaluating body fluid status. The search of PubMed and Medline databases was performed up to February 2019. Data from published reports and clinical observations show that the quick and noninvasive ultrasound examination facilitates the assessment of intravascular volume status and that the results correlate with other modalities, including invasive methods. Ultrasound enables physicians to determine the baseline status of hydration and to monitor the patient during fluid therapy. Additionally, it allows an assessment of asymptomatic patients, patients who are well adapted to chronic oxygen deficiency, and those who develop pulmonary congestion secondary to congestive heart failure or chronic kidney disease. The development of a protocol for an ultrasound assessment of the volume status would significantly facilitate the everyday practice of internal medicine specialists.
Diagnostic Bedside Ultrasonography for Acute Respiratory Failure and Severe Hypoxemia in the Medical Intensive Care Unit: Basics and Comprehensive Approaches.
Lui Justin K,Banauch Gisela I
Journal of intensive care medicine
Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in the critically ill patient population. The bedside intensivist is in a unique position to integrate ultrasound findings with the overall clinical situation. Medically critically ill patients who require urgent bedside diagnostic assessment fall into 2 categories: (1) acute respiratory failure and (2) hemodynamic derangements. The first portion of this review outlines the diagnostic role of bedside ultrasound in the medically critically ill patient population for the diagnosis and treatment of acute respiratory failure, acute respiratory distress, and severe hypoxemia. The second portion will focus on the diagnostic role of ultrasound for the evaluation and treatment of shock states, as well as describe protocolized approaches for evaluation of shock during cardiopulmonary resuscitation. Different respiratory system pathologies that result in acute respiratory failure (such as increased interstitial fluid, alveolar consolidation, pleural effusion) cause characteristic ultrasonographic findings; diaphragmatic assessment may also add information. Intracardiac shunting can cause severe hypoxemia. Protocolized approaches for the evaluation of patients with acute respiratory failure or distress are discussed.
Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France.
Bobbia X,Abou-Badra M,Hansel N,Pes P,Petrovic T,Claret P G,Lefrant J Y,de La Coussaye J E,
Anaesthesia, critical care & pain medicine
OBJECTIVE:Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011. METHODS:We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone. RESULTS:Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS. CONCLUSION:Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.