Sean P. Wilson

Implementation of a 4-Year Point-of-Care Ultrasound Curriculum in a Liaison Committee on Medical Education–Accredited US Medical School

The established benefits of point‐of‐care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education. This study sought to measure the educational success of a comprehensive and integrated 4‐year point‐of‐care ultrasound curriculum.

Hypertrophic Cardiomyopathy in Youth Athletes Successfull Screening With Point-of-Care Ultrasound by Medical Students

Hypertrophic cardiomyopathy (HCM) is a life‐threatening genetic cardiovascular disease that often goes undetected in young athletes. Neither history nor physical examination are reliable to identify those at risk. The objective of this study is to determine whether minimally trained medical student volunteers can use ultrasound to screen for HCM.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay.

BACKGROUND The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS). METHODS This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment. RESULTS We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01). CONCLUSION In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.

A Prospective Evaluation of Transverse Tracheal Sonography During Emergent Intubation by Emergency Medicine Resident Physicians

Establishing a definitive airway is often the first step in emergency department treatment of critically ill patients. Currently, there is no agreed upon consensus as to the most efficacious method of airway confirmation. Our objective was to determine the diagnostic accuracy of real‐time sonography performed by resident physicians to confirm placement of the endotracheal tube during emergent intubation.

Ventricular tachycardia cardiac arrest during central line placement

Central venous catheterization is often necessary for the safe administration of medications that are caustic to peripheral veins, to place temporary transvenous pacemakers and to provide invasive hemodynamic monitoring in the critically ill. While a wide range of complications are known to occur with insertion of these catheters, there is a paucity of cases associated with cardiac arrest during the catheters placement. We describe an unusual case of sustained ventricular tachycardia and subsequent cardiac arrest that occurred during an ultrasound guided central venous catheter placement for a patient in septic shock. This case serves as a reminder of the rare, but potentially fatal complication of central venous access placement.

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study.

BACKGROUND The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%-93.5%) and specificity of 100% (95%CI 15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively. CONCLUSION Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Identifying disparity in emergency department length of stay and admission likelihood.

BACKGROUND To assess whether insurance status has an effect on emergency department (ED) length of stay (LOS) and likelihood for admission or transfer to an operating room. METHODS This was a retrospective cross-sectional study of all encounters from January 2011 through October 2013 at an urban, academic trauma center. Analysis included multi-variable linear regression for ED LOS and logistic regression for the likelihood of admission. RESULTS Overall, 201 535 patients met the inclusion criteria, for which the mean age was 43.8 years, 55.9% were female, 23.4% were uninsured and 8% were of non-black race. Admission rate was 24.5% and operative rate was 1.4%. After adjusting for age, sex, triage acuity and race, the presence of insurance coverage was associated with an increased ED LOS of 575 (95%CI 552-598) vs. 567 (95%CI 543-591) minutes (P<0.01) among admitted patients and a decreased ED LOS of 456 (95%CI 381-531) vs. 499 (95%CI 423-575) minutes (P<0.01) among those transferred to an operating room. Adjusting for these same predictors, insured status remained a predictor for admission (odds ratio 1.24, 95%CI 1.20-1.28, P<0.01) and a negative predictor for transfer to the operating room (odds ratio 0.84, 95%CI 0.77-0.92, P<0.01). CONCLUSION The insured experienced a clinically insignificant increase in ED LOS when admitted and a 43-minute decrease in ED LOS when being transferred to the operating room. The insured were more likely to be admitted and less likely to be transferred to an operating room.

Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture.

BACKGROUND The objective of this study is to determine if point-of-care ultrasound (POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture (LP). METHODS This was a prospective, randomized controlled trial comparing POCUS pre-procedure identification of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit. RESULTS A total of 158 patients were enrolled. No significant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation. CONCLUSION Consistent with findings of previous studies, our data indicate that there was no observed benefit of using POCUS to identify pre-procedure landmarks when performing an LP.

Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers.

Introduction The goal of this study was to investigate the efficacy of diagnosing shoulder dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed by undergraduate research students, and to establish the range of measured distance that discriminates dislocated shoulder from normal. Methods We enrolled a prospective, convenience sample of adult patients presenting to the emergency department with acute shoulder pain following injury. Patients underwent ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa and the humeral head. The sonographic measurement of the distance between these two anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD represented a posterior position of the glenoid rim relative to the humeral head and a negative GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of the derived US method were calculated. Results A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation on conventional radiography, all of which were anterior. All confirmed dislocations had a negative measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation. This method demonstrated a sensitivity of 100% (95% CI [82.4–100]), specificity of 100% (95% CI [94.5–100]), positive predictive value of 100% (95% CI [82.4–100]), and negative predictive value of 100% (95% CI [94.5–100]). Conclusion Our study suggests that a single, posterior-approach POCUS can diagnose anterior shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as non-medical trainees, after a brief educational session. Further validation studies are necessary to confirm these findings.

Ultrasound-guided central venous access: which probe is preferred for viewing the subclavian vein using a supraclavicular approach?

BACKGROUND Point-of-care ultrasound guidance using a linear probe is well established as a tool to increase safety when performing a supradiaphragmatic cannulation of the internal jugular central vein. However, little data exist on which probe is best for performing a supradiaphragmatic cannulation of the subclavian vein. METHODS This was a prospective, observational study at a single-site emergency department, where 5 different physician sonologists evaluate individual practice preference for visualization of the subclavian vein using a supraclavicular approach with 2 different linear probes and 1 endocavitary probe. RESULTS Of 155 patients enrolled, there was no clear preference any of the probes (P= .03). After pooling linear probe preference, there was a preference for either linear probe over the alternative endocavitary probe (76.8% vs 23.1%, P< .05). CONCLUSION We observed a preference for a linear probe over an endocavitary probe. Further investigation is necessary to determine which probe is optimal for this application.