Megan M. Leo

Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism

STUDY OBJECTIVE The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnells sign). METHODS This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnells sign). The patients medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis. RESULTS Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnells sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded. CONCLUSION Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.

A Practical Guide to Self-Sustaining Point-of-Care Ultrasound Education Programs in Resource-Limited Settings

The value of point-of-care ultrasound education in resource-limited settings is increasingly recognized, though little guidance exists on how to best construct a sustainable training program. Herein we offer a practical overview of core factors to consider when developing and implementing a point-of-care ultrasound education program in a resource-limited setting. Considerations include analysis of needs assessment findings, development of locally relevant curriculum, access to ultrasound machines and related technological and financial resources, quality assurance and follow-up plans, strategic partnerships, and outcomes measures. Well-planned education programs in these settings increase the potential for long-term influence on clinician skills and patient care.

Image Segmentation and Machine Learning for Detection of Abdominal Free Fluid in Focused Assessment With Sonography for Trauma Examinations A Pilot Study

The objective of this pilot study was to test the feasibility of automating the detection of abdominal free fluid in focused assessment with sonography for trauma (FAST) examinations. Perihepatic views from 10 FAST examinations with positive results and 10 FAST examinations with negative results were used. The sensitivity and specificity compared to manual classification by trained physicians was evaluated. The sensitivity and specificity (95% confidence interval) were 100% (69.2%–100%) and 90.0% (55.5%–99.8%), respectively. These findings suggest that computerized detection of free fluid on abdominal ultrasound images may be sensitive and specific enough to aid clinicians in their interpretation of a FAST examination.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus

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.

Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals

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.

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS development and implementation.

Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic

Introduction Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events. Methods This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed. Results We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x2=51.7, p<0.001). Hydronephrosis on EP-performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size >5mm less likely (NPV 89%; LR− 0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03). Conclusion Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.

Delphi method validation of a procedural performance checklist for insertion of an ultrasound-guided peripheral intravenous catheter ☆ ☆☆ ★

Presentations:  New England Regional Meeting, Society Academic Emergency Medicine (SAEM/NERDS) Worcester, MA; March 30, 2016  Society of Academic Emergency Medicine (SAEM) Annual Conference New Orleans, LA; May 13, 2016

377 Right Ventricular Strain on Bedside Echocardiography: Does It Help in the Diagnosis of a Pulmonary Embolism?

Study Objectives: Treatment of deep venous thrombosis accounts for 600,000 hospitalizations per year. Despite literature advocating an outpatient treatment protocol for these patients, many hospitals continue to admit these patients in order to observe, arrange follow-up and educate patients prior to discharge. The diversity of cases that are being handled in an emergency department (ED) observation unit continues to grow as hospitals look to provide quality patient care, yet minimize cost. To date, no studies have described the treatment of deep venous thrombosis in an ED observation unit. Our primary objective was to evaluate the feasibility of a structured ED observation unity deep venous thrombosis treatment protocol. Methods: We performed a prospective observational trial of patients placed in the ED observation unity deep venous thrombosis treatment protocol from April 1 st 2010 to March 1st, 2011. The study was performed at William Beaumont Hospital, a tertiary care facility with an annual ED census of 118,000 patients. During this pilot, patients with an uncomplicated acute deep venous thrombosis were placed in the ED observation unity at the discretion of the treating emergency physician. To pilot the treatment of deep venous thrombosis in an ED observation unity, we developed a structured treatment algorithm focusing on 4 key facets of deep venous thrombosis management. First, we initiated treatment with low-molecular weight heparin and warfarin. This included a monitored self-administration of the second dose of low-molecular weight heparin in the ED observation unity. Second, we created an in-depth educational component including a video presentation and pamphlet describing deep venous thrombosis, low-molecular weight heparin and warfarin as well as potential risks and complications. Third, we observed the patient for a minimum of 12 hours for any signs of bleeding complications or pulmonary embolus. Fourth, we arranged follow-up with our anticoagulation monitoring service. Our primary outcome measures were admission, death, bleeding complications or pulmonary embolus on the index visit and at 30 days. Our secondary outcome measure was the cost difference between ED observation unit and admitted patients during the same period. Data was analyzed using descriptive statistics; confidence intervals were reported using a modified Wald method. Results: During the pilot study period 28 patients were treated with the ED observation unity deep venous thrombosis protocol. 7 (25%) of the patients were female with an average age of 56.6 ϩ/Ϫ 15.3. Within the pilot group there were 0 (C.I. 0.00% to 10.5%) deaths, bleeding complications or …

This Article Corrects: "Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model"

[This corrects the article on p. 649 in vol. 19, PMID: 30013699.].