Shadi Lahham

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis

STUDY OBJECTIVE We assess the diagnostic accuracy of emergency physician-performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology. METHODS We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphys sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. RESULTS Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). CONCLUSION The test characteristics of emergency physician-performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.

Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis

Objectives To evaluate the accuracy of emergency physicians using bedside ultrasound to detect appendicitis (BUSA). Methods Patients presenting to the emergency department with a clinical suspicion of appendicitis were prospectively enrolled and received a 5-min BUSA. Patients received routine work-up for acute appendicitis as deemed appropriate by the attending physician. Radiologists and consulting surgeons were blinded to BUSA results. The criterion standard for the presence or absence of acute appendicitis was the pathology report for patients who received appendectomies, and telephone follow-up for patients discharged home without surgical intervention. Results A total of 132 patients were enrolled. In 44 cases BUSA was positive. Of these, 37 had surgical pathology reports consistent with acute appendicitis, whereas seven did not have appendicitis. In 82 cases, BUSA was negative. Of these, 62 were determined not to have appendicitis, whereas 20 had appendicitis by pathology. Sensitivity for BUSA was 65% [95% confidence interval (CI) 52–76], specificity was 90% (95% CI 81–95), positive predictive value was 84% (95% CI 71–92), and negative predictive value was 76% (95% CI 65–84). The likelihood ratio of a positive BUSA was 6.4 (95% CI 3.1–13.2). Five patients discharged home with a diagnosis other than appendicitis were unable to be reached by telephone, and were excluded from data analysis. Conclusion Our study gives insufficient evidence to support the use of bedside ultrasound by emergency physicians to rule out appendicitis. The high specificity in our study, however, suggests that with further training, BUSA may be useful to rule-in appendicitis in some patients.

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.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field

BACKGROUND Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%). CONCLUSION Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Retrospective Review of Ocular Point-of-Care Ultrasound for Detection of Retinal Detachment

Introduction Retinal detachment is an ocular emergency that commonly presents to the emergency department (ED). Ophthalmologists are able to accurately make this diagnosis with a dilated fundoscopic exam, scleral depression or ophthalmic ultrasound when a view to the retina is obstructed. Emergency physicians (EPs) are not trained to examine the peripheral retina, and thus ophthalmic ultrasound can be used to aid in diagnosis. We assessed the accuracy of ocular point-of-care ultrasound (POCUS) in diagnosing retinal detachment. Methods We retrospectively reviewed charts of ED patients with suspected retinal detachment who underwent ocular POCUS between July 2012 and May 2015. Charts were reviewed for patients presenting to the ED with ocular complaints and clinical concern for retinal detachment. We compared ocular POCUS performed by EPs against the criterion reference of the consulting ophthalmologist’s diagnosis. Results We enrolled a total of 109 patients. Of the 34 patients diagnosed with retinal detachment by the ophthalmologists, 31 were correctly identified as having retinal detachment by the EP using ocular POCUS. Of the 75 patients who did not have retinal detachment, 72 were ruled out by ocular POCUS by the EP. This resulted in a POCUS sensitivity of 91% (95% CI [76–98]) and specificity of 96% (95% CI [89–99]). Conclusion This retrospective study suggests that ocular POCUS performed by EPs can aid in the diagnosis of retinal detachment in ED.

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.

A feasibility study to determine if minimally trained medical students can identify markers of chronic parasitic infection using bedside ultrasound in rural Tanzania

BACKGROUND Parasitic infections pose a significant health risk in developing nations and are a major cause of morbidity and mortality worldwide. In the Republic of Tanzania, the CDC estimates that 51.5% of the population is infected with one or more intestinal parasites. If diagnosed early, the consequences of chronic parasitic infection can potentially be avoided. METHODS Six first-year medical students were recruited to enroll patients in the study. They underwent ten hours of formal, hands-on, ultrasound which included basic cardiac, hepatobiliary, renal, pulmonary and FAST scan ultrasound. A World Health Organization protocol with published grading scales was adapted and used to assess for pathology in each patients liver, bladder, kidneys, and spleen. RESULTS A total of 59 patients were enrolled in the study. Students reported a sensitivity of 96% and specificity of 100% for the presence of a dome shaped bladder, a sensitivity and specificity of 100% for bladder thickening, a sensitivity and specificity of 100% for portal hypertension and ascites. The sensitivity was 81% with a specificity of 100% for presence of portal vein distention. The sensitivity was 100% with a specificity of 90% for dilated bowel. CONCLUSIONS Ultrasound has shown a promise at helping to identify pathology in rural communities with limited resources such as Tanzania. Our data suggest that minimally trained first year medical students are able to perform basic ultrasound scans that can identify ultrasonographic markers of parasitic infections.

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.