David M. Tierney

Point-of-Care Ultrasonography for Primary Care Physicians and General Internists

Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.

Internal medicine point-of-care ultrasound assessment of left ventricular function correlates with formal echocardiography

Although focused cardiac ultrasonographic (FoCUS) examination has been evaluated in emergency departments and intensive care units with good correlation to formal echocardiography, accuracy for the assessment of left ventricular systolic function (LVSF) when performed by internal medicine physicians still needs independent evaluation.

Ultrasound guidance for lumbar puncture

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.

Case report: an unrecognized etiology of transient gallbladder pain in heart failure diagnosed with internist-performed point-of-care ultrasound

The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timing of this test in a patient with fluctuating symptoms is not widely recognized as having a significant impact on its sensitivity. However, we present a case report describing the essential role of symptom-timed point-of-care ultrasound in making an elusive diagnosis of transient cholecystalgia in a patient with RUQ pain and congestive heart failure (CHF). This case also demonstrates an important etiology of RUQ pain in patients with CHF beyond that of congestive hepatopathy. A review of the related entities of acalculous cholecystitis, congestive hepatopathy, and diffuse gallbladder wall thickening is provided.

Hospital Privileging Practices for Bedside Procedures: A Survey of Hospitalist Experts

Many hospitalists are routinely granted hospital privileges to perform invasive bedside procedures, but criteria for privileging are not well described. We conducted a survey of 21 hospitalist procedure experts from the Society of Hospital Medicine Point‐of‐Care Ultrasound Task Force to better understand current privileging practices for bedside procedures and how those practices are perceived. Only half of all experts reported their hospitals require a minimum number of procedures performed to grant initial (48%) and ongoing (52%) privileges for bedside procedures. Regardless, most experts thought minimums should be higher than those in current practice and should exist alongside direct observation of manual skills. Experts reported that the use of ultrasound guidance was nearly universal for paracentesis, thoracentesis, and central venous catheter placement, but only 10% of hospitals required the use of ultrasound for initial privileging of these procedures.

Skull and Sinus

Traditional outpatient diagnosis of acute rhinosinusitis frequently results in overuse of antibiotics. Point-of-care ultrasound (POCUS) of the maxillary sinus is specific for clinically important fluid, but may miss subtle abnormalities that are rarely clinically important. The ethmoid and frontal sinuses are more challenging to image and are infrequently abnormal in isolation from the maxillary sinus. The absence of maxillary sinus fluid is a strong reason to avoid antibiotics in most patients, and helps reassure them. However, a patient with fever, severe symptoms suggestive of sinusitis, but no fluid with maxillary ultrasound, may need a computerized tomography (CT) scan to look for isolated ethmoid, frontal, or sphenoid sinusitis. A few clinical studies, and our clinic’s experience, suggest that ultrasound can substantially reduce antibiotic use for sinusitis [1–3], although there are no large randomized trials to confirm this. Only 23% of patients suspected of sinusitis in our clinic had positive ultrasound [3]. The presence of fluid does not differentiate between viral and bacterial disease, so the final antibiotic decision requires integration of ultrasound with the rest of the patient findings.

Evaluation of Shortness of Breath

Although thoracic ultrasound was thought to be impracticable for decades due to air interference, understanding of anatomy and artifacts has made it possible to gain a tremendous amount of clinical information from insonation of the chest. First described by European intensivists, thoracic ultrasound has become a powerful tool in the assessment of patients with undifferentiated shortness of breath or trauma.Thoracic ultrasound has been used to assess for pneumothorax (with a 99% negative predictive value in ruling out this process) in the setting of trauma and medical illness [2, 3]. It is also accurate in diagnosing and following pulmonary edema, pneumonia, pleural effusion, and other pulmonary pathology [2, 4–6].

Pulmonary ultrasound scoring system for intubated critically ill patients and its association with clinical metrics and mortality: A prospective cohort study

Pulmonary ultrasound (PU) examination at the point‐of‐care can rapidly identify the etiology of acute respiratory failure (ARF) and assess treatment response. The often‐subjective classification of PU abnormalities makes it difficult to document change over time and communicate findings across providers. The study goal was to develop a simple, PU scoring system that would allow for standardized documentation, have high interprovider agreement, and correlate with clinical metrics.

Certification of Point-of-Care Ultrasound Competency

1Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas; 2Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas; 3Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, Minnesota; 4Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California; 5Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont; 6Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire.

Ultrasound guidance for lumbar punctureAuthors Respond

I read the article by Soni et al.1 line by line. Because of my association with a hospital at the epicenter of the AIDS epidemic, I have performed many thousands of lumbar punctures (LPs) for all of the usual reasons. Many patients were tapped repeatedly. I am right-handed and so the LP is performed with the patient in the left lateral decubitus position. This is essential to measure the opening pressure. I mark the back in the usual fashion using the line between the superior iliac crests to identify the L4-L5 interspace. I prefer the L2-L3 interspace for the procedure. Once identified, I begin the procedure. I use the same words with each patient and prep and drape the patient in the same fashion each time. I use local anesthesia. Once I again have the L2 spinous process identified, I keep my left thumb firmly pressed there for guidance and support and to distract the patient. The needle is advanced perpendicular to the skin and once it has passed the bone is at times angled cephalad. What I have described is a ritual. It is the ritual that makes the successful LP and this can be taught.