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Background Corrected carotid flow time (CFTc) and carotid blood flow (CBF) are sonographic measurements used to assess fluid responsiveness in hypotension. We investigated the impacts of mechanical ventilation on CFTc and CBF. Materials and methods Normotensive patients undergoing cardiac surgery were prospectively enrolled. Carotid ultrasound (US) was performed pre and post-intubation. Post-intubation measurements took place after the initiation of mechanical ventilation. To measure CFTc and CBF, a sagittal carotid view was obtained with pulse wave-Doppler (maximum angle 60°). CFTc was calculated with the Bazett formula (CFTc = systolic time/√cycle time). CBF was calculated using CBF (mL/min) = area (cm  2  ) x time average mean velocity (TAMEAN) (cm/sec) x 60 (sec/min). The maximum carotid diameter was measured at the level of the thyroid. Results Twenty patients were enrolled. Mean CFTc pre-intubation was 328 ms (SD 43.9 ms) compared to CFTc post-intubation 336 ms (SD 36 ms). There was no significant difference between pre and post-intubation CFTc (mean differences=-0.008; t(19)=-0.71, p=.49). Mean CBF pre-intubation was 487 mL/min (SD 176 mL/min) compared to CBF post-intubation 447 mL/min (SD 187 mL/min). There was no significant difference between pre and post-intubation CBF (mean differences= 40; t(19)=1.24, p=.23). Conclusions In this study of normotensive patients, there were no detected differences in CFTc or CBF pre and post-intubation with mechanical ventilation., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2021, Schleifer et al.)

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.

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., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., (© 2020 Wiley Periodicals, Inc.)

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., (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: Point-of-care ultrasound (POCUS) is increasingly used in internal medicine, but a lack of trained faculty continues to limit the spread of POCUS education. Using a framework based on organizational change theories, this study sought to identify barriers and enablers for hospital-based practicing internists to learn and use POCUS in clinical practice., Methods: We invited practicing internists at six North American institutions to participate in an electronic survey on their opinions regarding 39 barriers and enablers., Results: Of the 342 participants invited, 170 participated (response rate 49.3%). The top barriers were lack of training (79%), lack of handheld ultrasound devices (78%), lack of direct supervision (65%), lack of time to perform POCUS during rounds (65%), and lack of quality assurance processes (53%). The majority of participants (55%) disagreed or strongly disagreed with the statement "My institution provides funding for POCUS training." In general, participants' attitudes towards POCUS were favourable, and future career opportunities and the potential for billing were not considered significant factors by our participants in the decision to learn or use POCUS., Conclusions: This survey confirms the perceived importance of POCUS to practicing internists. To assist in closing faculty development gap, interventions should address training, supervision, quality assurance processes, availability of handheld devices, as well as dedicated time to perform POCUS during clinical care.

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., (© 2018 by the American Institute of Ultrasound in Medicine.)

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. Our objective was 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 Harvard Medical School 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 first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum., Conclusion: POCUS can effectively be integrated into the existing medical school curriculum by using 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 four years of medical school., Competing Interests: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none

Background: Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use., Methods: The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method., Results: During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients., Conclusions: This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world., (Copyright © 2014. Published by Mosby, Inc.)

Objectives: Treatment failure rates for incision and drainage (I&D) of skin abscesses have increased in recent years and may be attributable to an increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Previous authors have described sonographic features of abscesses, such as the presence of interstitial fluid, characteristics of abscess debris, and depth of abscess cavity. It is possible that the sonographic features are associated with MRSA and can be used to predict the presence of MRSA. The authors describe a potential clinical decision rule (CDR) using sonographic images to predict the presence of CA-MRSA., Methods: This was a pilot CDR derivation study using databases from two emergency departments (EDs) of patients presenting to the ED with uncomplicated skin abscesses who underwent I&D and culture of the abscess contents. Patients underwent ultrasound (US) imaging of the abscesses prior to I&D. Abscess contents were sent for culture and sensitivity. Two independent physicians experienced in soft tissue US blinded to the culture results and clinical data reviewed the images in a standardized fashion for the presence or absence of the predetermined image characteristics. In the instance of a disagreement between the initial two investigators, a third reviewer adjudicated the findings prior to analysis. The association between the primary outcome (presence of MRSA) and each sonographic feature was assessed using univariate and multivariate analysis. The reliability of each sonographic feature was measured by calculating the kappa (κ) coefficient of interobserver agreement. The decision tree model for the CDR was created with recursive partitioning using variables that were both reliable and strongly associated with MRSA., Results: Of the total of 2,167 patients who presented with skin and soft tissue infections during the study period, 605 patients met inclusion criteria with US imaging and culture and sensitivity of purulence. Among the pathogenic organisms, MRSA was the most frequently isolated, representing 50.1% of all patients. Six of the sonographic features were associated with the presence of MRSA, but only four of these features were reliable using the kappa analysis. Recursive partitioning identified three independent variables that were both associated with MRSA and reliable: 1) the lack of a well-defined edge, 2) small volume, and 3) irregular or indistinct shape. This decision rule demonstrates a sensitivity of 89.2% (95% confidence interval [CI] = 84.7% to 92.7%), a specificity of 44.7% (95% CI = 40.9% to 47.8%), a positive predictive value of 57.9 (95% CI = 55.0 to 60.2), a negative predictive value of 82.9 (95% CI = 75.9 to 88.5), and an odds ratio (OR) of 7.0 (95% CI = 4.0 to 12.2)., Conclusions: According to our putative CDR, patients with skin abscesses that are small, irregularly shaped, or indistinct, with ill-defined edges, are seven times more likely to demonstrate MRSA on culture., (© 2014 by the Society for Academic Emergency Medicine.)

Background: Diagnosing the underlying cause of acute dyspnea can be challenging. Lung ultrasound may help to identify pulmonary edema as a possible cause., Objective: To evaluate the ability of residents to recognize pulmonary edema on lung ultrasound using chest radiographs as a comparison standard., Methods: This is a prospective, blinded, observational study of a convenience sample of resident physicians in the Departments of Emergency Medicine (EM), Internal Medicine (IM), and Radiology. Residents were given a tutorial on interpreting pulmonary edema on both chest radiograph and lung ultrasound. They were then shown both ultrasounds and chest radiographs from 20 patients who had presented to the emergency department with dyspnea, 10 with a primary diagnosis of pulmonary edema, and 10 with alternative diagnoses. Cohen's κ values were calculated to describe the strength of the correlation between resident and gold standard interpretations., Results: Participants included 20 EM, 20 IM, and 20 Radiology residents. The overall agreement with gold standard interpretation of pulmonary edema on lung ultrasound (74%, κ = 0.51, 95% confidence interval 0.46-0.55) was superior to chest radiographs (58%, κ = 0.25, 95% confidence interval 0.20-0.30) (P < 0.0001). EM residents interpreted lung ultrasounds more accurately than IM residents. Radiology residents interpreted chest radiographs more accurately than did EM and IM residents., Conclusion: Residents were able to more accurately identify pulmonary edema with lung ultrasound than with chest radiograph. Physicians with minimal exposure to lung ultrasound may be able to correctly recognize pulmonary edema on lung ultrasound.

Background: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings., Methods: A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus., Results: Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear., Conclusions: This document reflects the overall results of the first consensus conference on "point-of-care" lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

Background: The EFAST (extended focused assessment with sonography for trauma) is part of the recommended curriculum for Emergency Medicine and Surgery residents. Computer-based lectures may represent a time-efficient alternative to traditional lectures., Objectives: Our hypothesis was that computer lectures in basic ultrasound and the EFAST are not inferior to classroom lectures in test score improvement for residents with or without prior training., Methods: First-year Emergency Medicine and Surgery residents were enrolled and completed a pre-test. Subjects were then randomized into a classroom group, which attended traditional lectures, and a computer group, which listened to narrated lectures on computers. After the didactic training, all subjects completed a post-test., Results: Forty-four subjects completed the study: 64% were General Surgery residents, 66% were male. Overall, mean test score improvements were higher in the classroom than in the computer group (28.0% vs. 18.4%). In 25 residents without prior training, mean improvements in the computer and classroom groups were 25% and 27%, respectively. The 95% confidence limit around the difference was 9%, falling within the a priori non-inferiority range of 10%, and consistent with non-inferiority of computer-based lectures. In 19 residents with prior training, mean test score improvements for the computer and classroom groups were 13% and 29%, respectively. The 95% confidence limit of 24% exceeded the non-inferiority range, consistent with inferiority of computer-based lectures., Conclusions: Computer-based lectures are not inferior to classroom lectures and may represent a worthwhile substitution in subjects without prior ultrasound education. Our data suggest that didactic ultrasound training through classroom lectures is more effective than computer-based lectures in individuals with prior training., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Point-of-care ultrasound is being increasingly implemented in resource-poor settings in an ad hoc fashion. We developed a focused maternal ultrasound-training program for midwives in a rural health district in Zambia. Four hundred forty-one scans were recorded by 21 midwives during the 6-month study period. In 74 scans (17%), the ultrasound findings prompted a change in clinical decision-making. Eight of the midwives were evaluated with a 14-question observed structured clinical examination (OSCE) and demonstrated a slight overall improvement with mean scores at 2 and 6 months of 10.0/14 (71%) and 11.6/14 (83%), respectively. Our pilot project demonstrates that midwives in rural Zambia can be trained to perform basic obstetric ultrasound and that it impacts clinical decision-making. Ultrasound skills were retained over the study period. More data is necessary to determine whether the introduction of ultrasound ultimately improves outcomes of pregnant women in rural Zambia., (Copyright 2010 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: An aortic dissection is a life-threatening process that must be diagnosed and treated expeditiously. Imaging modalities used for diagnosis in the emergency department include computed tomography, magnetic resonance imaging, and trans-esophageal echocardiography. There are significant limitations to these studies, including patient contraindications (intravenous contrast dye allergies, renal insufficiency, metal-containing implants, hemodynamic instability) and the length of time required for study completion and interpretation by a radiologist or cardiologist., Objectives: A case is presented that demonstrates how emergency physicians can use trans-thoracic and abdominal bedside ultrasound to diagnose a type A aortic dissection., Case Report: A 72-year-old woman presented with chest pain radiating to her neck and back that was concerning for aortic dissection. This was subsequently confirmed and further classified as a type A dissection by bedside emergency physician-performed ultrasound. The images showed a clear intimal flap in the abdominal aorta, a dilatated aortic root, and extension of the intimal flap into the left common carotid artery. With prompt diagnosis, the patient was able to have emergent surgical consultation, confirmatory imaging, and intervention before further complication occurred., Conclusion: This case provides an example of how emergency trans-thoracic and abdominal ultrasound can be used to promptly diagnose a type A aortic dissection and expedite further consultation and prompt management., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Sonographic B-lines, also known as lung comets, have been shown to correlate with the presence of extravascular lung water (EVLW). Absent in normal lungs, these sonographic findings become prominent as interstitia and alveoli fill with fluid. Characterization of the dynamics of B-lines, specifically their rate of disappearance as volume is removed, has not been previously described. In this study, we describe the dynamics of B-line resolution in patients undergoing hemodialysis., Methods: Patients undergoing hemodialysis underwent three chest ultrasound examinations: before, at the midpoint, and after dialysis. We followed a previously described chest ultrasound protocol that counts the number of B-lines visualized in 28 lung zones. Baseline demographics, assessment of ejection fraction, time elapsed, net volume of fluid removed, and subjective degree of shortness of breath were recorded for each patient., Results: Forty of 45 patients completed full dialysis runs and had all three lung scans performed; 6 of 40 patients had zero or one B-line predialysis, and none of these 6 patients gained B-lines during dialysis. Thirty-four of 40 patients had statistically significant reductions in the number of B-lines from predialysis to the midpoint scan and from predialysis to postdialysis with a p value < 0.001. There was no association between subjective dyspnea scores and number of B-lines removed., Conclusions: B-line resolution appears to occur real-time as fluid is removed from the body, and this change was statistically significant. These data support thoracic ultrasound as a useful method for evaluating real-time changes in EVLW and in assessing a patient's physiologic response to the removal of fluid., Trial Registration: Massachusetts General Hospital trial registration protocol No. 2007P 002226.

Background: While ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers., Methods: 27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded., Results: Pre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement., Conclusion: This brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.