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Background Breath samples collected from patients infected with respiratory viruses are necessary for viral detection using breath analyzer devices. Given the highly transmissible nature of many of these illnesses, sample collection requires a multi-layered approach to ensure the safety of the research staff responsible for obtaining and transporting these samples. Our team established a protocol to minimize exposure to and transmission of COVID-19 when collecting breath samples. Methods We collected breath samples from 64 participants, of which 31 (48.4%) were positive for SARS-CoV-2 at the time of their visit. Before we started sample collection, biosafety inspection was conducted. We used a five-pronged approach to enhance safety and minimize transmission. First, we collected specimens in an outdoor space while the patients were seated in their vehicles. Second, we used a disposable mouthpiece and a one-way valve to fill a 1L TEDLAR bag. Third, patients were instructed to close the valve tightly before returning it to the staff. Fourth, we placed the bag in secondary containers which were placed in tertiary containers to minimize any contact with aerosols in the TEDLAR bag. In the last step, we placed a portable HEPA filter near the indoor sample processing unit to minimize exposure and air contamination with the samples. Study staff donned all forms of necessary personal protective equipment, including gloves, gowns, N95 respirators, and protective eyewear, during sample collection and transportation. Results A total of 64 breath samples were collected from 64 adult participants from February to March 2022. A total of 30 participants (46.9%) were within 7 days of their initial diagnosis. All participants were able to successfully collect samples without additional resources or attempts. All samples were able to be transported successfully into the lab. No staff contracted COVID-19 during the study period. Conclusion Layered safety measures, including protective equipment, physical barriers, and well-ventilated environments mitigated the risks associated with breath sample collections from infected participants. Disclosures Yvonne A. Maldonado, MD, Pfizer: Grant/Research Support|Pfizer: Member, DSMB, Pfizer Meningococcal Vaccine clinical trial.

Supplemental Digital Content is available in the text., Problem The COVID-19 pandemic significantly disrupted point-of-care ultrasound (POCUS) education. Medical schools and residency programs placed restrictions on bedside teaching and clinical scanning as part of risk mitigation. In response, POCUS faculty from 15 institutions nationwide collaborated on an alternative model of ultrasound education, A Distance-learning Approach to POCUS Training (ADAPT). Approach ADAPT was repeated monthly from April 1 through June 30, 2020. It accommodated 70 learners, who included 1- to 4-week rotators and asynchronous learners. The curriculum included assigned prework and learning objectives covering 20 core POCUS topics. A rotating group of 30 faculty and fellows delivered daily virtual teaching sessions that included gamification to increase learner engagement and hands-on instruction through teleguidance. After participation, faculty and learners completed anonymous surveys. Outcomes Educators reported a significant decrease in preparatory time (6.2 vs 3.1 hours per week, P < .001) dedicated to ultrasound education after implementing ADAPT. The majority of 29 learners who completed surveys felt “somewhat confident” or “very confident” in their ability to acquire (n = 25, 86.2%) and interpret (n = 27, 93.1%) ultrasound images after the intervention; the majority of 22 educators completing surveys rated the program “somewhat effective” or “very effective” at contributing to learner’s ability to acquire (n = 13, 59.1%) and interpret (n = 20, 90.9%) images. Most learners (n = 28, 96.6%) and all educators (n = 22, 100%) were “satisfied” or “very satisfied” with ADAPT as a whole, and the large majority of educators were “very likely” (n = 18, 81.8%) to recommend continued use of this program. Next Steps A virtual curriculum that pools the efforts of multiple institutions nationwide was implemented rapidly and effectively while satisfying educational expectations of both learners and faculty. This collaborative framework can be replicated and may be generalizable to other educational objectives.

Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method.We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at80%.Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus.Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

Aims Determining which patients with pericardial effusion require urgent intervention can be challenging. We sought to develop a novel, simple risk prediction score for patients with pericardial effusion. Methods and results Adult patients admitted through the emergency department (ED) with pericardial effusion were retrospectively evaluated. The overall cohort was divided into a derivation and validation cohort for the generation and validation of a novel risk score using logistic regression. The primary outcome was a pericardial drainage procedure or death attributed to cardiac tamponade within 24 h of ED arrival. Among 195 eligible patients, 102 (52%) experienced the primary outcome. Four variables were selected for the novel score: systolic blood pressure 3 cm (2 points)], right ventricular diastolic collapse (2 points), and mitral inflow velocity variation > 25% (1 point). The need for pericardial drainage within 24 h was stratified as low ( Conclusion Among ED patients with pericardial effusion, a four-variable prediction score consisting of systolic blood pressure, effusion diameter, right ventricular collapse, and mitral inflow velocity variation can accurately predict the need for urgent pericardial drainage. Prospective validation of this novel score is warranted.

OBJECTIVES: Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes. METHODS: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage. RESULTS: N = 160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P < .01) and consolidations (70 vs 46%; P < .01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P < .01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P < .01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P = .047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P < .01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P < .01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset. CONCLUSIONS: Lung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.

Introduction Ultrasound-guided peripheral intravenous catheter (US-PIVC) placement is an effective technique to establish PIV access when the traditional approach fails. Many training programs utilize commercial or homemade phantoms for procedural training. However, commercial products tend to be expensive and lack realism, while homemade blocks tend to be single-use and degrade easily. Thanks to the increasing availability of three-dimensional (3D) printers in academic settings, we sought to design and develop a reusable 3D-printed US-PIVC phantom and to evaluate its utility in terms of time needed to achieve IV placement and perceived realism compared to a commercial model among a group of emergency medicine (EM) physicians. Methods The upper extremity vascular phantom was constructed using 3D printing and casting techniques. A convenience sampling of EM physicians was timed by placing a US-PIVC in the 3D-printed and commercial models. Participants were also surveyed to assess their impression of the realism of the models. The primary outcome was the time required for US-PIVC placement in the 3D-printed model compared to the commercial model. Secondary outcomes were the assessment of differences in perceived realism and total cost between the two models. Results Twenty-one EM physicians completed the study. There were no significant differences in the mean time (seconds) for US-PIVC placement in the 3D-printed model (31, SD: 21) compared to the commercial model (30, SD: 18), p=0.77. Mean realism score trended higher for the 3D-printed model (3.6, SD: 0.9) compared to the commercial model (3.1, SD: 1.0), p=0.10. The total cost for the 3D-printed model was $120, with the interchangeable replacement part costing $21, which was much cheaper compared to the commercial phantom, which cost $549. Conclusion We developed a 3D-printed reusable US-PIVC phantom, and it proved to be more economical without sacrificing the realism and time required for US-PIVC placement when compared to a commercial phantom.

Introduction: Point-of-care (POC) echocardiography (echo) is a useful adjunct in the management of cardiac arrest. However, the practice pattern of POC echo utilization during management of cardiac arrest cases among emergency physicians (EP) is unclear. In this pilot study we aimed to characterize the utilization of POC echo and the potential barriers to its use in the management of cardiac arrest among EPs. Methods: This was a cross-sectional survey of attending EPs who completed an electronic questionnaire composed of demographic variables (age, gender, year of residency graduation, practice setting, and ultrasound training) and POC echo utilization questions. The first question queried participants regarding frequency of POC echo use during the management of cardiac arrest. Branching logic then presented participants with a series of subsequent questions regarding utilization and barriers to use based on their responses. Results: A total of 155 EPs participated in the survey, with a median age of 39 years (interquartile range 31-67). Regarding POC echo utilization, participants responded that they always (66%), sometimes (30%), or never (4.5%) use POC echo during cardiac arrest cases. Among participants who never use POC echo, 86% reported a lack of training, competency, or credentialing as a barrier to use. Among participants who either never or sometimes use POC echo, the leading barrier to use (58%) reported was a need for improved competency. Utilization was not different among participants of different age groups (P = 0.229) or different residency graduation dates (P = 0.229). POC echo utilization was higher among participants who received ultrasound training during residency (P = 0.006) or had completed ultrasound fellowship training (P

IntroductionPoint-of-care ultrasound (POCUS) may detect the cardiopulmonary manifestations of COVID-19 and expediently predict patient outcomes.MethodsWe conducted a prospective cohort study at four medical centers from 3/2020-1/2021 to evaluate POCUS findings and clinical outcomes with COVID-19. Our inclusion criteria included adult patients hospitalized for COVID-19 who received cardiac or lung POCUS with a 12-zone protocol. Images were interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was ICU admission incidence. Secondary outcomes included intubation and supplemental oxygen usage.ResultsN=160 patients (N=201 scans) were included. Scans were collected a median 23 hours (IQR:7-80) from emergency department triage. Triage POCUS findings associated with ICU admission included B-lines (OR 4.41 [95% CI:1.71-14.30]; pConsolidations present on triage were associated with the need for oxygen at discharge (OR 2.16 [95% CI: 1.01-4.70]; p=0.047). A normal lung triage scan was protective for ICU admission (OR 0.28 [95% CI:0.09-0.75; pDiscussionLung POCUS findings detected early in the hospitalization may provide expedient risk stratification for important COVID-19 clinical outcomes, including ICU admission, intubation, or need for oxygen on discharge. A normal admission scan appears protective against adverse outcomes, which may aid in triage decisions of patients.

Introduction: Point-of-care ultrasound (POCUS) can detect the cardiopulmonary manifestations of COVID-19 and may predict patient outcomes in an expedient and cost-effective manner. Methods: We conducted a prospective cohort study at four medical centers from 3/2020 to 9/2020 to evaluate the relationship between POCUS findings and clinical outcomes with COVID-19. Our inclusion criteria included adult patients hospitalized for COVID-19 who received lung ultrasound (LUS) examinations at the bedside with a 12-zone protocol. All images were interpreted by at least two reviewers who were blinded to clinical outcomes. Results: N=99 patients met inclusion criteria. The median time from ED triage to LUS was 0.9 days (IQR: 0.1-2.9). LUS was rarely normal (11% of patients), with B-lines (90%) and subpleural consolidations (62%) representing the most prevalent findings. Findings associated with ICU admission included anterior B-lines (OR: 3.1 [95% CI: 1.2-9.7]), anterior consolidations (OR: 3.1 [95% CI: 1.1-9.9]) and lateral consolidations (OR: 4.1 [95% CI: 1.3-15.5]), while a normal scan was strongly protective against ICU admission (OR 0.08 [95% CI: 0.00-0.68]). LUS findings remained stable over a period of 28 days from symptom onset. Discussion: Anterior and/or lateral lung involvement on POCUS may portend a three to four-fold risk of critical illness among COVID-19 patients. The location, rather than the absolute appearance of POCUS findings, may be important harbingers of severe disease. POCUS findings did not change over a 28-day scanning period, suggesting that their detection at any time point may be clinically important. Funding Statement: None to declare Declaration of Interests: None to declare. Ethics Approval Statement: This study was approved by the Institutional Review Boards of Stanford University and the University of California, San Francisco. A waiver of consent was obtained by both institutions.

BACKGROUND: The serratus anterior plane block (SAPB) is a safe, single‐injection alternative for pain control in patients with rib fractures. This pilot study aims to teach the ultrasound‐guided SAPB to emergency medicine (EM) residents using a mastery learning approach. METHODS: A 19‐item checklist was created and mastery was determined to be 17 of 19 items correct. This pass score was established using a Mastery Angoff standard‐setting exercise with a group of EM experts. Learners participated in baseline testing on a simulated model and performance was assessed by two raters. Learners then watched an instructional video and participated in an individualized teaching session. Learners underwent deliberate practice followed by posttesting until mastery was achieved. Score differences in baseline testing and posttesting were analyzed using a paired t‐test. Pre‐ and posttesting surveys were also completed by participants. RESULTS: Twenty‐eight PGY‐1 to ‐4 residents volunteered to participate in the study. The range of reported SAPBs seen previously was 0 to 5. The mean (±SD) number of items correct on the checklist for initial testing was 8.5 of 19 (±2.7), while the mean (±SD) final score was 18 of 19 (±0.6; p

BackgroundLung ultrasound (LUS) may be used in the diagnostic evaluation of patients with COVID-19. An abnormal LUS is associated with increased risk for ICU admission in COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown.Research QuestionWhat is the interrater reliability of lung ultrasound findings in patients with RT-PCR confirmed COVID-19?Study Design and MethodsThis study was conducted at conducted at two academic medical centers between 03/2020-06/2020. Nine physicians (hospitalists: n=4; emergency medicine: n=5) independently evaluated n=20 LUS scans (n=180 independent observations) collected from RTPCR confirmed COVID-19 patients. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (κ) were used to calculate IRR.ResultsThere was substantial IRR on the following items: normal LUS scan (κ=0.79 [95% CI: 0.72-0.87]), presence of B-lines (κ=0.79 [95% CI: 0.72-0.87]), >=3 B-lines observed (κ=0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (κ=0.57 [95% CI: 0.50-0.64]), subpleural consolidation (κ=0.49 [95% CI: 0.42-0.56]), and presence of effusion (κ=0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (κ=0.23 [95% CI: 0.15-0.30]).InterpretationMany LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.Clinicaltrials.gov Registration:NCT04384055DisclosuresAndre Kumar, MD, MEd is a paid consultant for Vave Health, which manufactures one of the ultrasound devices used in this study. His consultant duties include providing feedback on product development. The other authors do not have any items to disclose.

Introduction: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement. Methods: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5–1.9 cm), or abnormal (1.9 cm was 91.4% (95% CI, 88.4–94.3%) and 90.8% (95% CI, 87.7–93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1–2) to 3 (IQR 3–4) points after participation in the study. Conclusion: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.

IntroductionPoint-of-care ultrasound (POCUS) has the potential to transform healthcare delivery in the era of COVID-19 with its diagnostic and therapeutic expediency. It can be performed by clinicians already at the bedside, which permits an immediate and augmented assessment of a patient. Although lung ultrasound can be used to accurately diagnose a variety of disease states such as pneumothorax, pleural effusions, pneumonia and interstitial lung disease2, there are limited reports on the sonographic manifestations of COVID-19. There is an urgent need to identify alternative diagnostic modalities that can be immediately employed at the bedside of COVID-19 patients.MethodsThis study was conducted at two medical centers in the United States from 3/21/2020-6/01/2020. Any adult who was hospitalized with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) and received a pulmonary POCUS examination was included. Providers were instructed to use a 12-zone scanning protocol for pulmonary views and save 6 second clips of each lung zone. This study utilized several POCUS devices, including Butterfly IQ, Vave, Lumify, and Sonosite. The collected images were interpreted by the study researchers based on a consensus document developed by the study authors and previously accepted definitions of lung POCUS findings.ResultsA total of 22 eligible patients who received 36 lung scans were included in our study. Eleven (50%) patients experienced clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset). Among the 36 lung scans collected, only 3 (8%) were classified as normal. The remaining scans had the following abnormalities: presence of B-lines (n=32, 89%), consolidations (n=20, 56%), pleural thickening (n=17, 47%), and pleural effusion (n=4, 11%). Out of 20 scans with consolidations, 14 (70%) were subpleural and 5 (25%) were translobar. A-lines were present in 26 (72%) of patients, although they were only observed in the majority of the collected lung zones in 5 (14%) of patients. Ultrasound findings were stratified by time from symptom onset to the scan based on the following time periods: early (0-6 days), middle (7-13 days), and late (14-28 days). B-lines appeared early after symptom onset and persisted well into the late disease course. In contrast, pleural thickening increased in frequency over time (early: 25%, middle: 47%, late: 67%). Subpleural consolidations also appeared in higher frequency later in the disease course (early: 13%, middle 42%, late: 56%).Discussioncertain lung ultrasound findings may be common in Covid-19, while others may appear later in the disease course or only occur in patients who experience clinical deterioration. Future efforts should investigate the predictive utility of consolidations, pleural thickening and B-lines for clinical deterioration and compare them to traditional radiological studies such as X-rays or CTs.

Objectives The aim of this study was to evaluate the accuracy and timeliness of resident-performed point-of-care lung ultrasound (LUS) examinations for the follow-up of pneumothorax (PTX) after tube thoracostomy. Methods After brief training, Rwandan surgical residents blinded to chest radiography (CXR) performed and interpreted LUS examinations for PTX in participants undergoing CXR for PTX follow-up. Treating clinicians interpreted CXR for the presence of PTX for therapeutic decisions. Lung ultrasound was later reviewed by ultrasound experts, and CXR was reviewed by a radiologist. We defined expert LUS interpretation as the reference standard. The sensitivity and specificity of resident-performed LUS examinations for diagnosing PTX were calculated. We assessed agreement between trained resident versus expert LUS and clinician versus radiology CXR using the Cohen κ coefficient. We compared the time to results between LUS and CXR. Results Over an 8-month period, 51 participants were enrolled. Compared to expert LUS interpretation, the sensitivity and specificity (95% confidence intervals) of resident LUS were 100% (85%-100%) and 96% (82%-100%), respectively, whereas the sensitivity and specificity of clinician-interpreted CXR were 48% (27%-69%) and 100% (88%-100%). The agreement between resident and expert LUS was excellent (κ = 0.96), whereas the agreement between clinician and radiologist CXR was only moderate (κ = 0.60). The time to results was significantly longer for CXR than LUS (mean, 1335 versus 396 minutes; P = .0001). Conclusions A resident-performed LUS examination was a quicker imaging modality with superior sensitivity compared to clinician-interpreted CXR for PTX follow-up after tube thoracostomy in this Rwandan study. Lung ultrasound can be a valuable imaging tool for PTX follow-up, especially in resource-limited settings.

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.

Case Presentation: An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome. Discussion: Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.