Robert Arntfield

Focused Transesophageal Echocardiography by Emergency Physicians is Feasible and Clinically Influential: Observational Results from a Novel Ultrasound Program

BACKGROUND Emergency physicians frequently employ transthoracic echocardiography (TTE) to assist in diagnosis and therapy for patients with circulatory failure or arrest. In critically ill patients, transesophageal echocardiography (TEE) offers several advantages over TTE, including reliable, continuous image acquisition and superior image quality. Despite these advantages, TEE is not widely used by emergency physicians. OBJECTIVE Report the feasibility, findings, and clinical influence observed from the first described TEE program implemented in an emergency department (ED) point-of-care ultrasound program. METHODS This was a retrospective review of all ED TEE examinations carried out between February 1, 2013 and January 30, 2015. TEE images and report details (including operator, indication, findings, and clinical recommendation[s]) were exported from the institutional ultrasound archive and analyzed. The electronic chart of each patient was subsequently reviewed for the presence of any complications related to the examination and their clinical course in the hospital. RESULTS A total of 54 TEE examinations were performed by 12 different emergency physicians. All patients were intubated, and 98% of the examinations were determinate. The most common indications for TEE were intracardiac arrest care in 23 (43%), postarrest management in 14 (26%), and undifferentiated hypotension in 16 (40%). Probe insertion was successful in all cases. TEE imparted a diagnostic influence in 78% of cases and impacted therapeutic decisions in 67% of cases. CONCLUSION From our analysis of a single-center experience, ED-based TEE showed a high degree of feasibility and clinical utility, with a diagnostic and therapeutic influence seen in the majority of cases. Focused TEE demonstrated strongest uptake among intubated patients with either undifferentiated shock or cardiac arrest.

Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination

BackgroundTransesophageal echocardiography (TEE) offers several advantages over transthoracic echocardiography (TTE). Despite these advantages, use of TEE by emergency physicians (EPs) remains rare, as no focused TEE protocol for emergency department (ED) use has been defined nor have methods of training been described.ObjectiveThis study aims to develop a focused TEE examination tailored for the ED and to evaluate TEE skill acquisition and retention by TEE-naïve EPs following a focused 4-h curriculum.MethodsAcademic EPs were invited to participate in a 4-h didactic and simulation-based workshop. The seminar emphasized TEE principles and views obtained from four vantage points. Following the training, participants engaged in an assessment of their abilities to carry out a focused TEE on a high-fidelity simulator. A 6-week follow-up session assessed skill retention.ResultsFourteen EPs participated in this study. Immediately following the seminar, 14 (100 %; k = 1.0) and 10 (71.4 %, k = 0.65) successfully obtained an acceptable mid-esophageal four-chamber and mid-esophageal long-axis view. Eleven (78.6 %, k = 1.0) participants were able to successfully obtain an acceptable transgastric short-axis view, and 11 (78.6 %, k = 1.0) EPs successfully obtained a bicaval view. Twelve participants engaged in a 6-week retention assessment, which revealed acceptable images and inter-rater agreement as follows: mid-esophageal four-chamber, 12 (100 %; k = 0.92); mid-esophageal long axis, 12 (100 %, k = 0.67); transgastric short-axis, 11 (91.7 %, k = 1.0); and bicaval view, 11 (91.7 %, k = 1.0).ConclusionThis study has illustrated that EPs can successfully perform this focused TEE protocol after a 4-h workshop with retention of these skills at 6 weeks.

The utility of remote supervision with feedback as a method to deliver high-volume critical care ultrasound training.

OBJECTIVE Despite international agreement that critical care ultrasound (CCUS) is an essential skill for intensive care providers, CCUS training and dissemination is complicated by a shortage of educators. Newer technology now permits remote, offline supervision as a method of overseeing trainees undergoing CCUS instruction. DESIGN This was a retrospective, descriptive report of a CCUS curriculum and its output of clinical ultrasound examinations at an academic critical care training program over a 1-year period. The curriculum consisted of typical didactic and hands-on training as well as wireless archiving of examinations with remote, offline oversight and feedback provided by the director using ultrasound management software. SETTING A tertiary-care, academic critical care training program. MEASUREMENTS AND MAIN RESULTS Twenty-nine trainees acquired and archived a total of 2531 CCUS studies (average 76 studies per trainee) for 1 year. Of these, 1807 (71%) examinations had a typewritten report generated by the operator, and 1788 of these examinations were overread and subjected to feedback from the curriculum director. The predominant application of CCUS was for cardiac (62%), thoracic (32%), and abdominal (5%) assessment. CONCLUSIONS This study suggests that the use of wireless archiving and offline oversight in a CCUS curriculum is a feasible and highly-efficient strategy permitting a small number of faculty to supervise a large number of trainees. This approach provides an efficient method to address unmet demand for CCUS education.

The Rapid Assessment of Competency in Echocardiography Scale Validation of a Tool for Point-of-Care Ultrasound

Increased use of point‐of‐care ultrasound (US) requires the development of assessment tools that measure the competency of learners. In this study, we developed and tested a tool to assess the quality of point‐of‐care cardiac US studies performed by novices.

Outcomes from extensive training in critical care echocardiography: Identifying the optimal number of practice studies required to achieve competency

Purpose Optimal instruction and assessment of critical care ultrasound (CCUS) skills requires an assessment tool to measure learner competency and changes over time. In this study, a previously published tool was used to monitor the development of critical care echocardiography (CCE) competencies, the attainment of performance plateaus, and the extent to which previous experience influenced learning. Materials and methods A group of experts used the Rapid Assessment of Competency in Echocardiography (RACE) scale to rate a large pool of CCE studies performed by novices in a longitudinal design. A total of 380 studies performed by twelve learners were assessed; each study was independently rated by two experts. Results Learners demonstrated improvement in mean RACE scores over time, with peak performance occurring early in training and a performance plateau thereafter. Learners with little experience received the greatest benefit from training, with an average performance plateau reached at the twentieth study. Conclusions Supporting earlier results, the RACE scale provided a straightforward means to assess learner performance with minimal requirements for evaluator training. The results of the present study suggest that novices experience the greatest gains in competency during their first twenty practice studies, a threshold which should serve to guide training initiatives. HighlightsWith the rise of point‐of‐care ultrasound and competency‐based education, there is an urgent need to tools to assess competencyA previously validated assessment tool was applied to a large cohort of cardiac ultrasound scans performed by novicesLeaners improved until the twentieth practice scan; this effect was more pronounced in less experienced leanersThe results suggest a threshold of twenty practice scans for learners as a reasonable starting point in training

Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation

&NA; Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

The introduction of basic critical care echocardiography reduces the use of diagnostic echocardiography in the intensive care unit

BACKGROUND Basic critical care echocardiography (CCE) is routinely used by intensive care unit (ICU) providers to rapidly address key hemodynamic questions for the critically ill. By comparison, diagnostic echocardiography (DE) uses a comprehensive examination with more traditional workflow and sophisticated techniques. Despite these differences, both are frequently used to answer similar questions in ICU. This overlap raises questions of duplicate testing and redundancy of hospital resources. We therefore evaluated the effect of the introduction of basic CCE over the use of DE in Victoria Hospital, a tertiary care ICU in London Ontario, Canada. METHODS The monthly mean ratios of basic CCE and DE studies to patient care days (PCD) were plotted and general linear models were used to test for trends over time. Student t test was used to compare the mean DE/PCD before and after the introduction of basic CCE. The ratio of management actions for basic CCE studies was described. Outcome measures were compared using Pearson χ(2) test of association or the Wilcoxon rank sum test. RESULTS Over the 2-year study period, 1264 basic CCE studies were performed. Over this time, the ratio of CCE/PCD increased significantly (P<.001), whereas the ratio of DE/PCD decreased significantly (P=.004). When comparing the pre- and post-CCE periods, the mean DE/PCD decreased significantly from 5.27% to 4.51% (P=.01). There was no adverse change in ICU outcomes before and after the introduction of basic CCE. Mortality rates (pre- and post-CCE) were 23.69% and 24.61% (P=.48); median length of stay was 4.18 and 3.53 days (P<.001); and ventilated patient day rate was 64.96% and 64.93% (P>.9). There was a significant increase in vasoactive/inotropic drugs from a 20.47% vasoactive/inotropic drug/patient day rate to 21.99% (P<.001). Of all basic CCE studies, 61% led to a specific management action, including ordering a DE in 10.7% of cases. CONCLUSION In a hospital with a significant increase in basic CCE use, an associated significant decrease in DE use was observed with no increase in adverse outcomes. The significant increase in basic CCE use resulted in a change of management in most cases including the request for DE in a minority of cases.

Bedside identification of blunt thoracic aortic injury with point-of-care transesophageal echocardiography

Trauma point-of-care ultrasound in the form of the Focused Assessment with Sonography for Trauma (FAST) exam and its evolution into extended FAST have significantly enhanced the diagnostic power of evaluation and resuscitation of the trauma patient; however, these modalities still have limitations in evaluating mediastinal and cardiac pathology. This report demonstrates a case of point-of-care transesophageal echocardiography in the diagnosis of blunt thoracic aortic injury in an unstable patient involved in a motor vehicle collision.

Focused assessment with sonography in trauma: a review of concepts and considerations for anesthesiology

The use of point-of-care ultrasound in trauma provides diagnostic clarity and routinely influences management. A scanning protocol known as the Focused Assessment with Sonography in Trauma (FAST) has been widely adopted by trauma providers of all specialties. The FAST exam addresses a broad array of pathologic conditions capable of causing instability, including hemoperitoneum, hemopericardium, hemothorax, and pneumothorax. The exam is an integral component to the primary assessment of injured patients and an iconic application of point-of-care ultrasound.This review article aims to summarize the application of the FAST exam with special consideration, where relevant, to anesthesiologists. The scope of the FAST exam, technical considerations, and clinical decision-making in trauma are explored.RésuméDans les cas de traumatisme, l’utilisation de l’échographie au chevet procure une facilité diagnostique et a souvent un impact sur la prise en charge. Un protocole d’examen, connu sous l’acronyme FAST (pour Focused Assessment with Sonography in Trauma, soit Évaluation ciblée du traumatisme grâce à l’échographie), a été largement adopté par les spécialistes de traumatologie dans toutes les spécialités. L’examen FAST porte sur un vaste éventail de conditions pathologiques pouvant provoquer une instabilité, y compris l’hémopéritoine, l’hémopéricarde, l’hémothorax et le pneumothorax. L’examen est une composante intégrale de l’évaluation initiale des patients blessés et une application phare de l’échographie au chevet.Ce compte rendu vise à résumer l’application de l’examen FAST et porte une attention particulière, le cas échéant, aux anesthésiologistes. L’objectif de l’examen FAST, des considérations techniques et la prise de décision clinique en trauma sont expliquées.

Critical care echocardiography: a certification pathway for advanced users

The content of this issue of Journal supports the broad overall acceptance that point-of-care ultrasound (POCUS) has achieved across many medical specialties. Despite this progress, fundamental confusion persists surrounding the achievement of both competency and certification in POCUS. In this editorial, we seek to demystify and clarify these issues from a Canadian critical care perspective, with special consideration of the recently announced examination and certification pathway in advanced critical care echocardiography. The landscape of competency and certification in POCUS cannot be understood without a firm grasp on the nomenclature that has been adopted thus far (Figure). For POCUS performed by intensivists, critical care ultrasound (CCUS) is the appropriate umbrella term, spanning the two main branches of critical care echocardiography (CCE) and general critical care ultrasound (GCCUS). Critical care echocardiography itself is divided into basic (BCCE) and advanced (ACCE) skill sets. A basic-level provider should be able to generate the five core transthoracic views, interpret left and right ventricular size and global function, identify a pericardial effusion, assess the inferior vena cava, and recognize catastrophic leftsided valvular pathology. So essential to the modern practice of critical care medicine, BCCE has been endorsed as a core skill for all intensivists by the worldwide critical care community and benefits from a growing evidence base. As with other essential intensivist skills (bronchoscopy, central venous access, airway management), BCCE (and likewise GCCUS) should be taught under local expert supervision during fellowship training. Importantly, formal certification for BCCE and GCCUS has been deemed unnecessary both internationally and by the unanimous consensus of Canadian CCUS experts, a position endorsed by the Canadian Critical Care Society in 2013. When it comes to advanced echocardiographic applications, there is a very important departure in the approach and philosophy surrounding training and certification. Advanced applications require greater cognitive and procedural skill, are more quantitative (and therefore subject to error), and are overall closer in scope to a diagnostic echocardiographic examination performed by a cardiologist or an intraoperative examination performed by a cardiac anesthesiologist. Within the scope of ACCE, an intensivist may use a transthoracic or transesophageal approach to address hemodynamic questions (cardiac output, volume responsiveness, or heart-lung interactions), to resolve diagnostic questions (shock etiology, source of embolism, endocarditis, or important valvular dysfunction), or to guide procedures (pacemaker insertion or extracorporeal membrane oxygenation cannulation). Due to this inherent sophistication and resemblance to comprehensive echocardiography, there is S. J. Millington, MD (&) Critical Care Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON, Canada e-mail: smillington@toh.ca