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As point-of-care ultrasound (POCUS) becomes more integrated into clinical practice, it is essential to address all aspects of ultrasound operator proficiency. Ultrasound proficiency requires the ability to acquire, interpret and integrate bedside ultrasound images. The difference in image acquisition psychomotor skills between novice (trainee) and expert (instructor) ultrasonographer has not been described. We created an inexpensive system, called Probe Watch, to record probe motion and assess image acquisition in cardiac POCUS using an inertial measurement device and software for data recording based on open-source components. We designed a temporal convolutional network for skills classification from probe motion that integrates clinical domain knowledge. We further designed data augmentation methods to improve its generalization. Subsequently, we validated the setup and assessment method on a set of novice and expert sonographers performing cardiac ultrasound in a simulation-based training environment. The proposed methods classified participants as novice or expert with areas under the receiver operating characteristic curve of 0.931 and 0.761 for snippets and trials, respectively. Integrating domain knowledge into the neural network had added value. Furthermore, we identified the most discriminative features for assessment. Probe Watch quantifies motion during cardiac ultrasound and provides insight into probe motion behavior. It may be deployed during cardiac ultrasound training to monitor learning curves objectively and automatically.

Ultrasound-guided pre-procedural planning decreases complications from bedside thoracentesis. Although rare, intercostal artery (ICA) laceration is a serious complication that occurs when vulnerable intercostal arteries (VICA) are no longer protected by the superior rib. We sought to determine if increasing patient age is associated with greater odds of encountering a VICA. Randomly selected in-patients underwent pre-procedural planning for a mock posterior bedside thoracentesis. ICAs were categorized as vulnerable if they were visible within the corresponding intercostal space (ICS). We recorded where the VICA entered and exited the ICS as well as its unshielded length. A total of 40 patients (20 male) were enrolled and 240 ICS (6 ICS per patient) were scanned. Within this cohort, 25% of patients were noted to have at least one VICA. We could not demonstrate any relationship between the patient’s age or location of the ICS, with the odds of encountering a VICA (odds ratio (OR) = 1.0, p = 0.76; OR = 0.85, p = 0.27, respectively). Given the haphazard nature of VICA distribution and poor outcomes associated with inadvertent laceration, we recommend that ICA screening at the site of needle insertion be routinely performed prior to thoracentesis.

Atraumatic chest pain is a common emergency department (ED) presentation and the American College of Cardiology and American Heart Association recommends stress testing within 72 hours. The HEART score predicts major adverse cardiac events (MACE) in ED populations and does not require universal stress testing. An evaluation based solely on history, electrocardiography, and biomarkers, therefore, is an attractive approach to risk stratification in resource-limited settings. The HEART score has not been previously evaluated in a safety net hospital setting. We therefore implemented an interdisciplinary clinical care guideline utilizing the HEART score to stratify patients presenting to our inner-city hospital. During a 6-month study period, 1170 patients were evaluated (521 before and 649 after implementation). Among the 998 patients with confirmed follow-up 6-weeks after the index ED encounter, the prevalence of MACE (all-cause mortality, acute myocardial infarction, or coronary revascularization) was 0% [95% confidence interval (CI), 0%-1%] for low, 9% (95% CI, 7%-12%) for moderate, and 52% (95% CI, 39%-65%) for high-risk groups. Guideline implementation significantly increased admissions (+12%, 95% CI, 7%-17%) primarily in the moderate risk group (+38%, 95% CI, 29%-47%), but significantly decreased median ED length of stay (-37 minutes, 95% CI, 17-58). It also led to an increase in stress testing among moderate and high-risk patients (+10%, 95% CI, 0%-19%). In conclusion, the HEART score effectively stratified risk of MACE in a safety net population, improved evaluation consistency, and decreased ED length of stay. However, implementation was associated with an increase in hospitalizations and stress testing. Although the American Heart Association/American College of Cardiology guideline regarding atraumatic chest pain in the ED recommends universal noninvasive testing, the value of this approach, particularly in conjunction with the HEART score is uncertain in safety net hospitals. Further evaluation of the costs and clinical advantages of this approach are warranted.

The journal retracts the article, ‘Is Increasing Age Associated with Higher Rates of Intercostal Arteries Vulnerable to Laceration [...]

In the outpatient setting, ambulatory electrocardiography is the most frequently used diagnostic modality for the evaluation of patients in whom cardiac arrhythmias or conduction abnormalities are suspected. Proper selection of the device type and monitoring duration is critical for optimizing diagnostic yield and cost-effective resource utilization. However, despite guidance from major professional societies, the lack of systematic guidance for proper test selection in many institutions results in the need for repeat testing, which leads to not only increased resource utilization and cost of care, but also suboptimal patient care. To address this unmet need at our own institution, we formed a multidisciplinary panel to develop a concise, yet comprehensive algorithm, incorporating the most common indications for ambulatory electrocardiography, to efficiently guide clinicians to the most appropriate test option for a given clinical scenario, with the goal of maximizing diagnostic yield and optimizing resource utilization. The algorithm was designed as a single-page, color-coded flowchart to be utilized both as a rapid reference guide in printed form, and a decision support tool embedded within the electronic medical records system at the point of order entry. We believe that systematic adoption of this algorithm will optimize diagnostic efficiency, resource utilization, and importantly, patient care and satisfaction.

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Purpose of review: To review the literature and describe techniques to use ultrasound to guide performance of lumbar puncture (LP). Recent findings: Ultrasound evaluation of the lumbar spine has been shown in randomized trials to improve LP success rates while reducing the number of attempts and the number of traumatic taps. Summary: Ultrasound mapping of the lumbar spine reveals anatomical information that is not obtainable by physical examination, including depth of the ligamentum flavum, width of the interspinous spaces, and spinal bone abnormalities, including scoliosis. Using static ultrasound, the lumbar spine anatomy is visualized in transverse and longitudinal planes and the needle insertion site is marked. Using real-time ultrasound guidance, the needle tip is tracked in a paramedian plane as it traverses toward the ligamentum flavum. Future research should focus on efficient methods to train providers, cost-effectiveness of ultrasound-guided LP, and the role of new needle-tracking technologies to facilitate the procedure.