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BackgroundPoint-of-care lung ultrasound (LUS) examination is increasingly utilized in Internal Medicine. To improve the standardization of LUS education and clinical use, explicit minimal criteria for defining what is an acceptable and clinically useful image are needed.MethodsA 97-item online survey of potential minimal criteria for common uses of LUS in Internal Medicine was developed and sent to 10 international point-of-care ultrasound experts. Their opinion on the inclusion of each item was sought and items not achieving consensus (defined as agreement by at least 70% of the experts) were reassessed in subsequent rounds. A total of three rounds were conducted.ResultsSeventy-four minimal criteria were agreed upon for inclusion, 24 were agreed upon for exclusion, and two did not reach consensus.ConclusionsExperts agreed on 74 minimal criteria for Internal Medicine LUS. The use of these minimal criteria during teaching and clinical use is strongly recommended. RésuméContexteL’échographie pulmonaire au point d’intervention est de plus en plus utilisée en médecine interne. Pour améliorer l’uniformisation de la formation sur l’échographie pulmonaire et de son utilisation clinique, il faut des critères minimaux explicites pour définir ce qu’est une image acceptable et utile sur le plan clinique.MéthodologieUn sondage en ligne de 97 éléments portant sur des critères minimaux possibles dans l’utilisation courante de l’échographie pulmonaire en médecine interne a été élaboré et soumis à 10 experts internationaux en échographie au point d’intervention. Leur avis sur l’inclusion de chaque élément a été sondé, et les éléments pour lesquels il n’y avait pas de consensus (défini par l’accord d’au moins 70 % des experts) ont été réévalués lors de tours suivants. Au total, trois tours ont été effectués.RésultatsSoixante-quatorze critères minimaux ont été acceptés, 24 ont été exclus et deux n’ont pas fait consensus.ConclusionsLes experts se sont entendus sur 74 critères minimaux relatifs à l’échographie pulmonaire en médecine interne. L’utilisation de ces critères minimaux au cours de l’enseignement et de l’utilisation clinique est fortement recommandée.

Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients.This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points.153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%).A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Objectives To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19). Methods Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered. Results Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus. Conclusions In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Long-term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long-term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator-induced diaphragmatic dysfunction. Ventilator-induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post-acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long-term MV who underwent diaphragmatic US examinations to evaluate for ventilator-induced diaphragmatic dysfunction.

Background Herpes zoster (HZV) is a painful vesicular rash that occurs after reactivation in immunosuppressed patients. Analgesia in this patient population has been notoriously difficult. The serratus anterior and erector spinae plane block have both been described as effective thoracic analgesic techniques, but data are limited on their use in HZV. Case Report A middle-aged man with a history of hypertension and hyperlipidemia presented to the emergency department (ED) with chest and back pain associated with cutaneous rash. Traditional pain regimens were not effective; therefore, a serratus anterior plane block was performed using 25 mL of 0.25% of bupivacaine. The patient's pain decreased from 10 to 2 in 20 min and the patient was discharged without further analgesia. Why Should An Emergency Physician Be Aware of This? As opiate use decreases in prevalence and utility in the ED, alternatives to analgesia are sought. We describe the technique of regional anesthesia using a serratus anterior plane block as another modality that physicians can use to address HZV-related pain.

Background Proximal humeral fractures are commonly encountered in the emergency department (ED). These injuries are often associated with significant pain, with patients often receiving multiple doses of opiate medications while awaiting definitive management. The interscalene nerve block has been efficacious as perioperative analgesia for patients undergoing operative shoulder repair. The utilization of the interscalene nerve block in the ED for proximal humeral fractures is largely unexplored. Discussion We report the use of an ultrasound-guided interscalene nerve block in the ED for a patient presenting with significant pain from a proximal humerus fracture. The procedure provided excellent regional anesthesia with no additional need for intravenous or oral opiates during the rest of her ED course. With the significant risks associated with pain medication, particularly opiates, regional anesthesia may be an excellent option for the appropriate patient in the ED. Conclusions As documented in this report, the ultrasound-guided interscalene block, in particular, may be utilized as a means to provide adequate pain control for patients with proximal humerus fractures in the ED.

Objectives Difficult intravenous access (DIVA) is common in the emergency department (ED). We investigated the extent to which DIVA is associated with care delay outcomes including time to first laboratory draw, therapies, imaging, and ED disposition. Methods An observational retrospective cohort analysis of patients with DIVA treated between 2018 and 2020 at 2 urban academic EDs was performed. DIVA was defined as patients requiring ultrasound‐guided intravenous access placed by physicians or advanced practice providers (APPs) as opposed to landmark‐based intravenous placement by nurses. ED throughput variables and disposition time were compared. We correlated DIVA with time to administration of intravenous pain medications, fluids, imaging contrast, laboratory results, and ED disposition. Results A total of 108,256 subjects with 161,122 total encounters were included. DIVA occurred in 4961 (3.1%) of ED visits. Patients with DIVA were more likely to be female (3.5% vs 2.6% for males, odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.27–1.42), self‐identify as black (OR 1.78, 95% CI: 1.66–1.91), and have higher acuity of illness (P < 0.001). Among pediatric patients, DIVA occurred most often in the first year of life at a rate of 3.25%. In adults, DIVA occurred in 2 age peaks; at 35 years (4.02%), and at 63 years (3.44%). In all workflow metrics, the presence of DIVA was associated with significant delays in median time to completion: 50 minutes for pain medication administration, 36 minutes for intravenous fluid administration, 29 minutes for laboratory results, 57 minutes for intravenous contrast administration, and 87 minutes for discharge orders. Conclusion DIVA was associated with increased time to therapies, diagnostic studies, imaging completion, and ED disposition. A more expeditious approach to achieving intravenous access in patients with predicted DIVA could improve ED throughput and patient care overall.

Author(s): Duggan, Nicole M.; Liteplo, Andrew S.; Shokoohi, Hamid; Goldsmith, Andrew J. | Abstract: Introduction: First detected in December 2019, the severe acute respiratory syndrome coronavirus 2 pandemic upended the global community in a few short months. Diagnostic testing is currently limited in availability, accuracy, and efficiency. Imaging modalities such as chest radiograph (CXR), computed tomography, and lung ultrasound each demonstrate characteristic findings of coronavirus disease 2019 (COVID-19). Lung ultrasound offers benefits over other imaging modalities including portability, cost, reduced exposure of healthcare workers as well as decreased contamination of equipment such as computed tomography scanners.Case Series: Here we present a case series describing consistent lung ultrasound findings in patients with confirmed COVID-19 despite variable clinical presentations and CXR findings. We discuss a triage algorithm for clinical applicability and utility of lung point-of-care ultrasound in the setting of COVID-19 and advocate for judicious and targeted use of this tool.Conclusion: Lung point-of-care ultrasound can provide valuable data supporting diagnostic and triage decisions surrounding suspected cases of COVID-19. Prospective studies validating our proposed triage algorithm are warranted.

Background Point-of-care ultrasound (POCUS) competence consists of image acquisition, image interpretation, and clinical integration. Limited data exist on POCUS usage patterns and clinical integration by emergency medicine (EM) residents. We sought to determine actual POCUS usage and clinical integration patterns by EM residents and to explore residents' perspectives on POCUS clinical integration. Methods We conducted an explanatory sequential mixed-methods study at a 4-year EM residency program. In phase 1, EM ultrasound (US) attendings observed PGY-4 EM residents' clinical integration of POCUS in real time while on shift in the emergency department (ED). EM US attendings evaluated residents on their intent to perform POCUS, actual POCUS usage, and competence per patient encounter. We used logistic regression to analyze these parameters. In phase 2, we conducted semi-structured interviews with the observed PGY-4 residents regarding POCUS usage and clinical integration in the ED. We analyzed qualitative data for themes. Results Emergency medicine US attendings observed 10 PGY-4 EM residents during 254 high-acuity patient encounters from December 2018 to March 2019. EM US attendings considered POCUS indicated for 26% (66/254) of patients, possibly indicated for 12% (30/254) and not indicated for 62% (158/254). Of the 66 patients for whom EM US attendings considered POCUS indicated, PGY-4s intended to perform POCUS for patient management 61% (40/66) of the time. PGY-4s subsequently incorporated POCUS into patient management 73% (48/66) of the time. EM US attendings considered PGY-4s entrustable to perform POCUS independently 81% (206/254) of the time. We did not find a statistically significant association between shift volume, shift type, or POCUS application, and resident intent to perform POCUS nor competence. Interviews identified three factors that influence PGY-4's POCUS clinical integration: motivations to use POCUS, barriers to utilization, and POCUS educational methods. Conclusions This mixed-methods study identified a significant gap in POCUS utilization and clinical integration by PGY-4 EM residents for clinically indicated cases identified by EM US attendings. As clinical integration is a cornerstone of POCUS competence, it is important to ensure that EM resident POCUS curricula emphasize training on clinical utilization and indications for POCUS while on shift in the ED.

Ultrasound measurement of carotid intima-media thickness (CIMT) and plaque thickness (PT) may be an additional tool for risk stratification of patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). The aim of this study was to evaluate the correlation of CIMT and PT with coronary artery disease (CAD) in risk stratification tests.This prospective observational study was conducted in an academic tertiary care ED. Carotid ultrasound measurements were obtained for emergency patients with suspected ACS. Carotid measurements included PT, mean CIMT and maximum CIMT. The correlations between carotid ultrasound and the results of coronary catheter angiography (CA), coronary computed tomography angiography (CCTA) and stress tests were identified. The convenience sample included 58 patients comprising 39 men and 19 women with a mean age of 60 ± 12 y. Twenty-two percent (13/58) of patients were positive for CAD, as indicated by results of the cardiac risk stratification tests. Presence of plaque correlated with CCTA findings, with a high specificity (92.8%) for a positive test. Max CIMT predicted abnormal CCTA (area under the curve [AUC] = 0.93, 95% confidence interval: 0.80-1). The correlations with stress test (0.78, 0.46-1) and CA (0.55, 0.28-0.82) were weaker. Presence of carotid plaque correlated significantly with findings of CAD on all risk stratification tests, but especially with CCTA. Carotid ultrasound could have a role in risk stratification in the ED, though more research is needed.

The COVID-19 pandemic requires a new approach to point-of-care ultrasound (POCUS) education. Although virtual education offers a unique solution to didactic material, education that require hands-on learning is limited. POCUS education is predominantly done at the bedside and as a result could pose risk to health-care providers and patients as well as increase utilization of personal protective equipment (PPE). This paper discusses the challenges and unique solutions to address POCUS education in the era of COVID-19.

BACKGROUND Despite the utilization of point-of-care ultrasound (POCUS) by trauma surgeons, formal POCUS requirements do not exist for general surgery residents. We sought to evaluate surgery resident comfort with performing and interpreting of Extended-Focused Assessment for Sonography in Trauma (E-FAST) scans after a brief educational session. METHODS A pre-survey, sent to PGY-2 and -3 surgical residents before their trauma rotation, evaluated comfort with eight components of the E-FAST. Residents were then required to watch a 15-min online video and attend a 1-h bedside training session moderated by emergency medicine ultrasound fellows during which residents practised E-FAST image acquisition and interpretation. After the rotation, residents completed a post-survey evaluating their comfort with the E-FAST. RESULTS All 27 residents rotating on the trauma service during the 2017-2018 academic year were eligible and, therefore, approached by the study team. Twenty-one (77.78%) residents completed the pre-survey, training and post-survey. Initially, only 52% (13/25) of residents reported feeling confident in performing the E-FAST. After the session, all (100%) reported feeling confident in their training in E-FAST. Self-reported mean comfort with each of the eight components of the E-FAST showed a statistically significant (P

Point-of-care ultrasound of the diaphragm is a simple, noninvasive, dynamic bedside evaluation of diaphragm function that involves no ionizing radiation, does not require patient transport, and enables the serial evaluation of diaphragmatic function over time. Adverse effects on the diaphragm attributed to ventilator-induced diaphragm dysfunction include longer weaning times, ventilation time and weaning failure. Recent investigations of point-of-care ultrasound evaluating the expiratory muscles of the lateral abdominal wall have found similar adverse effects of mechanical ventilation on these important respiratory muscles resulting in weaning difficulty as well as impaired airway clearance. Children with medical complexity have significant chronic health conditions that may involve multisystem disease (congenital or acquired), high medical fragility, functional and psychosocial impairment, technology dependence (tracheostomies, mechanical ventilation, feeding tubes) and high resource utilization (frequent and/or prolonged hospitalizations). Weaning children dependent on mechanical ventilation is a common rehabilitation goal that has beneficial effects on the quality of life, ease of care, and functionality for transitioning to home care. We present a case of weaning difficulty in a child with medical complexity and the important role of point-of-care ultrasound in the evaluation of the diaphragm and expiratory muscles during a spontaneous breathing trial.

Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergency department. Angle-independent M-mode may provide a more accurate and consistent evaluation of diaphragmatic excursion, an examination that can be used to guide clinical care and anticipate outcomes.

ObjectivesTo assess the diagnostic performance of lung point-of-care ultrasound (POCUS) compared to either a positive nucleic acid test (NAT) or a COVID-19-typical pattern on computed tomography (CT) and to evaluate opportunities to simplify a POCUS algorithm.MethodsHospital-admitted adult inpatients with (1) either confirmed or suspected COVID-19 and (2) a completed or ordered CT within the preceding 24 hours were recruited. Twelve lung zones were scanned with a handheld POCUS machine. POCUS, CT, and X-ray (CXR) images were reviewed independently by blinded experts. A simplified POCUS algorithm was developed via machine learning.ResultsOf 79 enrolled subjects, 26.6% had a positive NAT and 31.6% had a CT typical for COVID-19. The receiver operator curve (ROC) for a 12-zone POCUS protocol had an area under the curve (AUC) of 0.787 for positive NAT and 0.820 for typical CT. A simplified four-zone protocol had an AUC of 0.862 for typical CT and 0.862 for positive NAT. CT had an AUC of 0.815 for positive NAT; CXR had AUCs of 0.793 for positive NAT and 0.733 for typical CT. Performance of the four-zone protocol was superior to CXR for positive NAT (p=0.0471). Using a two-point cutoff system, the four-zone POCUS protocol had a sensitivity of 0.920 and 0.904 compared to CT and NAT, respectively, at the lower cutoff; it had a specificity of 0.926 and 0.948 at the higher cutoff, respectively.ConclusionPOCUS outperformed CXR to predict positive NAT. POCUS could potentially replace other chest imaging for persons under investigation for COVID-19.

PURPOSE We sought to assess whether ultrasound (US) measurements of carotid flow time (CFTc) and carotid blood flow (CBF) predict fluid responsiveness in patients with suspected sepsis. METHODS This was a prospective observational study of hypotensive (systolic blood pressure

In patients with influenza, cardiac and lung ultrasound may help determine the severity of illness and predict clinical outcomes. To determine the ultrasound characteristics of influenza and define the spectrum of lung and cardiac findings in patients with suspected influenza A or B, we conducted a prospective observational study in patients presenting to the emergency department at a tertiary care academic institution. An ultrasound protocol consisting of cardiac, lung and inferior vena cava scans was performed within 6 h of admission. We compared the ultrasound findings in cases with positive and negative influenza polymerase chain reaction, while controlling for comorbidities. We enrolled 117 patients, 41.9% of whom (49/117) tested positive for influenza. In those with influenza, ultrasound confirmed preserved left ventricular and right ventricular (RV) function in 81.3% of patients. The most common cardiac pathology was RV dilation (10.4%), followed by left ventricular systolic dysfunction (8.3%). Patients with negative influenza polymerase chain reaction with RV dysfunction demonstrated higher hospital admission than those those with normal RV function (45.1%, 23/51, vs. 17.9%, 5/28; p = 0.016). B-lines were prevalent in both influenza and non-influenza groups (40.8% and 69.1%, respectively; p = 0.013). Lung consolidation was identified in only 8.25% of patients with influenza. In conclusion, in patients with influenza we were unable to define distinct ultrasound features specific to influenza A or B, suggesting that ultrasound may not be beneficial in diagnosing influenza nor in evaluating its severity.

Introduction Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield. Methods This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used. Results Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M. Conclusion POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs.

Study Objectives: As the upcoming influenza season aligns with a forecasted second wave of COVID-19, diagnostics are needed to effectively and efficiently differentiate between the two Point-of-care ultrasound (POCUS) is already widely used in the evaluation of cardiopulmonary dysfunction in the emergency setting, but scant research has been performed into the diagnostic implications of POCUS in patients with suspected influenza This study investigated the utility of cardiopulmonary ultrasound as a novel diagnostic tool for patients with influenza Methods: A convenience sample of patients presenting to an urban academic ED with influenza-like symptoms who received polymerase chain reaction (PCR) influenza testing were enrolled An ultrasonographer blinded to influenza results performed a POCUS using the CLIFF (Cardiac, Lungs, IVC, and Free fluid-t) protocol POCUS scans were performed by emergency medicine attendings, ultrasound fellows, or advanced practice providers who received 1-hour training in the CLIFF protocol Clinical data including demographics, relevant comorbidities, and influenza vaccine status as well as laboratory values, interventions, and disposition were retrospectively collected POCUS findings of PCR positive flu cases were then compared to PCR flu negative cases Descriptive analysis using Fisher’s exact test was used to compare the two groups’ findings A subgroup analysis adjusting for heart failure was then performed Results: A total of 117 patients were enrolled, of which 41 9% (49/117) tested positive for the flu Patients with flu negative had a higher rate of hospitalization (75 0%, 51/68;36 8% 25/117) and found to have more comorbidities including congestive heart failure (57 1%, 28/49;8 2% 4/49) (P=0 046;p=0 001) A subgroup analysis adjusted for CHF showed no statistical difference in POCUS findings of pulmonary b-lines (65 7%, 23/35;42 5%, 17/40;p=0 075), a-lines (85 7%, 30/35;82 5%, 33/40;p=0 95), consolidations (28 6%, 10/35;15%, 6/40;p=0 251) in cases with flu positive and negative Non-flu patients also showed significantly depressed EF as compared to flu-positive patients (25/68, 36 8%;4/38, 8 33%;p= 001), as well as significantly higher levels of RV dysfunction (8/68, 14%;1/48, 2 17%) and IVC dilation (15/68, 23 1%;2/48, 4 44%;p= 027) The proportion of patients with normal EF was higher in patients with flu compared to patients without flu (85 0% vs 65 7%, P = 0 042) Mild RV dilation was more prevalent in flu-negative patients Conclusion: In ED patients with suspected influenza, a POCUS CLIFF protocol showed no difference in cardiopulmonary findings in patients with confirmed influenza as compared to those who tested negative Further studies comparing POCUS cardiopulmonary findings of influenza compared to COVID-19 are needed [Formula presented]

Background Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. Objectives In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. Methods This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality. Results The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37–31.86), RV enlargement (OR 4.02, 95% CI 1.43–11.34), and a McConnell sign (OR 2.79, 95% CI 1.09–7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74–53.32). Conclusion In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.

A patient presented to the emergency department with altered mental status and lower extremity weakness in the setting of nitrous oxide inhalant abuse and Coronavirus Disease-2019 (COVID-19) infection. He subsequently developed hypotension and severe hypoxia, found to have a saddle pulmonary embolus (PE) with right heart strain requiring alteplase (tPA).

Background Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free. Objective Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety. Discussion In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS. Conclusions Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

Sciatic radicular back pain is a painful condition resulting in approximately 2% of emergency department (ED) visits a year. Typically, the ED treatment has been limited to various analgesic regimens with limited success sometimes resulting in hospital admissions for pain control. Regional anesthesia has become increasing popular for lower-limb analgesia, but has not universally permeated the ED setting. The transgluteal sciatic nerve block (TGSNB) is a procedure that can provide effective analgesia for lower extremity pain. Herein, we present the first technical description and clinical response to ultrasound-guided TGSNB performed by emergency physicians for acute pain control of sciatic back pain through a series of cases.

Recent applications of artificial intelligence (AI) and deep learning (DL) in health care include enhanced diagnostic imaging modalities to support clinical decisions and improve patients' outcomes. Focused on using automated DL-based systems to improve point-of-care ultrasound (POCUS), we look at DL-based automation as a key field in expanding and improving POCUS applications in various clinical settings. A promising additional value would be the ability to automate training model selections for teaching POCUS to medical trainees and novice sonologists. The diversity of POCUS applications and ultrasound equipment, each requiring specialized AI models and domain expertise, limits the use of DL as a generic solution. In this article, we highlight the most advanced potential applications of AI in POCUS tailored to high-yield models in automated image interpretations, with the premise of improving the accuracy and efficacy of POCUS scans.

Objectives Gamification is a powerful tool in medical education. SonoGames is a competitive games-based event designed to educate and inspire emergency medicine (EM) residents about point-of-care ultrasound. We sought to describe: (1) the perceived effectiveness of a competitive event on both immediate learning and long-term education; and (2) the resultant attitudes of participants and program directors regarding ultrasound training. Methods The SonoGames Organizational Committee designed 2 surveys: 1 for SonoGames V EM resident participants and a second for EM program directors. Survey questions used a 5-point Likert scale to assess overall perceptions and attitudes about ultrasound, changes in self-reported content knowledge and competency, effects on clinical use, and perceived impacts of a competitive game format on education. Results Seventy-three resident participants and 42 program directors responded to the survey. Ninety-four percent of participants thought that the competitive gaming format of SonoGames was effective in making the event an educational experience. Participants reported that their ultrasound knowledge increased (81%), their enthusiasm for ultrasound increased (87%), and their clinical use of ultrasound increased (61%). Residency program directors reported similar increases to a lesser degree. Greater advancement through the event was associated with more positive responses. Residencies that participated in the event saw greater increases in the use of ultrasound by residents than those that did not. Conclusions A competitive games-based educational event focused on point-of-care ultrasound is an effective educational tool. SonoGames increases EM residents' knowledge, enthusiasm, and clinical use of ultrasound both during and after the event.

Background Non-invasive measures that can accurately estimate cardiac output may help identify volume-responsive patients. This study seeks to compare two non-invasive measures (corrected carotid flow time and carotid blood flow) and their correlations with invasive reference measurements of cardiac output. Consenting adult patients (n = 51) at Massachusetts General Hospital cardiac catheterization laboratory undergoing right heart catheterization between February and April 2016 were included. Carotid ultrasound images were obtained concurrently with cardiac output measurements, obtained by the thermodilution method in the absence of severe tricuspid regurgitation and by the Fick oxygen method otherwise. Corrected carotid flow time was calculated as systole time/√cycle time. Carotid blood flow was calculated as π × (carotid diameter)2/4 × velocity time integral × heart rate. Measurements were obtained using a single carotid waveform and an average of three carotid waveforms for both measures. Results Single waveform measurements of corrected flow time did not correlate with cardiac output (ρ = 0.25, 95% CI −0.03 to 0.49, p = 0.08), but an average of three waveforms correlated significantly, although weakly (ρ = 0.29, 95% CI 0.02–0.53, p = 0.046). Carotid blood flow measurements correlated moderately with cardiac output regardless of if single waveform or an average of three waveforms were used: ρ = 0.44, 95% CI 0.18–0.63, p = 0.004, and ρ = 0.41, 95% CI 0.16–0.62, p = 0.004, respectively. Conclusions Carotid blood flow may be a better marker of cardiac output and less subject to measurements issues than corrected carotid flow time. Electronic supplementary material The online version of this article (doi:10.1186/s13089-017-0065-0) contains supplementary material, which is available to authorized users.

Objectives Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies. Methods We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy. Results Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28–2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%). Conclusions A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.

The importance of this study is to devise an efficient tool for assessing frailty in the ED. The goals of this study are 1) to correlate ultrasonographic (US) measurements of muscle thickness in older ED patients with frailty and 2) to correlate US-measured sarcopenia with falls, subsequent hospitalizations and ED revisits.Participants were conveniently sampled from a single ED in this prospective cohort pilot study of patients aged 65 or older. Participants completed a Fatigue, Resistance, Ambulation, Illness and Loss of Weight (FRAIL) scale assessment and US measurements of their upper arm muscles, quadricep muscles, and abdominal wall muscles thickness. We conducted one-month follow-up phone calls to assess for falls, ED revisits, and subsequent hospital visits.We enrolled 43 patients (mean age of 78.5). Ultrasound measurements of the three muscle groups were not significantly different between frail and non-frail groups. Frail participants had greater bicep asymmetry (a difference of 0.47 cm vs 0.24 cm, p .01). A predictive logistic regression model using average quadriceps thickness and biceps asymmetry was found to identify frail patients (AUC of 0.816). Participants with subsequent falls had smaller quadriceps (1.18 cm smaller, p .01). Subsequently hospitalized patients were found to have smaller quadriceps muscles (0.54 cm smaller, p = .03) and abdominal wall muscles (0.25 cm smaller, p = .01).US measurements of sarcopenia in older patients had mild to moderate associations with frailty, falls and subsequent hospitalizations. Further investigation is needed to confirm these findings.

In emergency department (ED) cases with clinically suspected diverticulitis, diagnostic imaging is often needed for diagnostic confirmation, to exclude complications, and to direct patient management. Patients typically undergo a CT scan in the ED; however, in a subset of cases with suspected diverticulitis, point-of-care ultrasound (POCUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management.We review the main sonographic features of diverticulitis and discuss the diagnostic accuracy and potential benefits of a POCUS First model.

BACKGROUND Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially. METHODS We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP]

Background Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. Case Report A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. Why Should an Emergency Physician Be Aware of This? In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.

Introduction: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. We report our efforts of integrating POCUS into the medical curriculum through a multi-disciplinary effort. Our objective is to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods: This was a pilot study to introduce ultrasonography into the “blinded for peer review” curriculum to first and second year medical students. Didactic and hands-on sessions were introduced to first year students during gross anatomy and to second year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam were measured by a post-assessment survey. RESULTS: All 1st year anatomy students (n=176) participated in small group hands-on US sessions. In the 2nd year physical diagnosis course, 38 students participated in 4 sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the 4 year medical school curriculum. CONCLUSIONS AND RELEVANCE: POCUS can effectively be integrated into the existing medical school curriculum by utilizing didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all 4 years of medical school.

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Background Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150–300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). Methods This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. Results Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343–361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289–409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351–360], which was slightly higher than the median OSCE score of 342 [IQR 326–361] in the group with less than 300 total scans (p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. Conclusion The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.

Objective The differential diagnoses of patients presenting with chest pain (CP) and shortness of breath (SOB) are broad and non-specific. We aimed to 1) determine how use of point-of-care ultrasound (POCUS) impacted emergency physicians' differential diagnosis, and 2) evaluate the accuracy of POCUS when compared to chest radiograph (CXR) and composite final diagnosis. Methods We conducted a prospective observational study in a convenience sample of patients presenting with CP and SOB to the Emergency Department (ED). Treating physicians selected possible diagnoses from a pre-indexed list of possible diagnoses of causes of CP and SOB. The final composite diagnosis from a chart review was determined as the reference standard for the diagnosis. The primary analysis involved calculations of sensitivity and specificity for POCUS identifiable diagnoses in detecting cause of CP and SOB. Additional comparative accuracy analysis with CXRs were conducted. Results 128 patients with a mean age of 64 ± 17 years were included in the study. Using a reference standard of composite final diagnoses, POCUS had equal or higher specificity to CXR for all indications for which it was used, except for pneumonia. POCUS correctly identified all patients with pneumothorax, pleural effusion and pericardial effusion. In patients with a normal thoracic ultrasound, CXR never provided any actionable clinical information. Adding POCUS to the initial evaluation causes a significant narrowing of the differential diagnoses in which the median differential diagnosis from 5 (IQR 3–6) to 3 (IQR 2–4) p Conclusion In evaluation of patients with CP and SOB, POCUS is a highly feasible diagnostic test which can assist in narrowing down the differential diagnoses. In patients with a normal thoracic ultrasound, the added value of a CXR may be minimal.

Objective We sought to determine test performance characteristics of emergency physician ultrasound for the identification of gastric contents. Methods Subjects were randomized to fast for at least 10 h or to consume food and water. A sonologist blinded to the patient's status performed an ultrasound of the stomach 10 min after randomization and oral intake, if applicable. The sonologist recorded their interpretation of the study using three sonographic windows. Subsequently 2 emergency physicians reviewed images of each study and provided an interpretation of the examination. Test performance characteristics and inter-rater agreement were calculated. Results 45 gastric ultrasounds were performed. The sonologist had excellent sensitivity (92%; 95% CI 73%–99%) and specificity (85%; 95% CI 62%–92%). Expert review demonstrated excellent sensitivity but lower specificity. Inter-rater agreement was very good (κ = 0.64, 95%CI 0.5–0.78). Conclusion Emergency physician sonologists were sensitive but less specific at detecting stomach contents using gastric ultrasound.