Vivek S. Tayal

Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians

The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician.

Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients*

Objective:We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. Design:Randomized, controlled trial of immediate vs. delayed ultrasound. Setting:Urban, tertiary emergency department, census >100,000. Patients:Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. Interventions:Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. Measurements and Main Results:Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p < .0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70–87%) of group 1 subjects vs. 50% (95% confidence interval, 40–60%) in group 2, difference of 30% (95% confidence interval, 16–42%). Conclusions:Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.

Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states

OBJECTIVES Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.

Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension.

The hypothesis of this study states that in emergency department (ED) patients with nontraumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with nontraumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were nontrauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohens κ for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57 ± 16.7 years, 59% were male, and the mean initial systolic blood pressure was 83 ± 11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of κ = 0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with nontraumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.

FAST (Focused Assessment With Sonography in Trauma) Accurate for Cardiac and Intraperitoneal Injury in Penetrating Anterior Chest Trauma

Objective. To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. Methods. An observational prospective study was conducted over a 30‐month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. Results. FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%–100%); specificity was 100% (95% confidence interval, 85.8%–100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%–99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%–100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false‐positive results, giving a specificity of 100% (95% confidence interval, 85.8%–100%). This prompted necessary laparotomy in all 8. Conclusions. In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.

Comparison of Serial Qualitative and Quantitative Assessments of Caval Index and Left Ventricular Systolic Function During Early Fluid Resuscitation of Hypotensive Emergency Department Patients

OBJECTIVES The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. METHODS This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship-trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. RESULTS Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. CONCLUSIONS This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.

AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination.

The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of guidelines, and accreditation. To promote this mission, the AIUM is pleased to publish, in conjunction with the American College of Emergency Physicians (ACEP), this AIUM Practice Guideline for the Performance of the Focused Assessment With Sonography for Trauma (FAST) Examination. We are indebted to the many volunteers who contributed their time, knowledge, and energy to bringing this document to completion. The AIUM represents the entire range of clinical and basic science interests in medical diagnostic ultrasound, and with hundreds of volunteers, the AIUM has promoted the safe and effective use of ultrasound in clinical medicine for more than 50 years. This document and others like it will continue to advance this mission. Practice guidelines of the AIUM are intended to provide the medical ultra-sound community with guidelines for the performance and recording of high-quality ultrasound examinations. The guidelines reflect what the AIUM considers the minimum criteria for a complete examination in each area but are not intended to establish a legal standard of care. AIUM-accredited practices are expected to generally follow the guidelines with the recognition that deviations from the guidelines will be needed in some cases depending on patient needs and available equipment. Practices are encouraged to go beyond the guidelines to provide additional service and information as needed by their referring physicians and patients.

Emergency Clinician–Performed Compression Ultrasonography for Deep Venous Thrombosis of the Lower Extremity

STUDY OBJECTIVE Emergency clinician-performed ultrasonography holds promise as a rapid and accurate method to diagnose and exclude deep venous thrombosis. However, the diagnostic accuracy of emergency clinician-performed ultrasonography performed by a heterogenous group of clinicians remains undefined. METHODS Prospective, single-center study conducted at an urban, academic emergency department (ED). Clinician participants included ED faculty, supervised residents, and midlevel providers who completed a training course for above-calf, 3-point-compression, venous ultrasonography. Patient participants had suspected leg deep venous thrombosis and greater than or equal to 1 predefined sign or symptom. Before any imaging, clinicians classified patients as low (<15%), moderate (15% to 40%), or high (>40%) pretest probability of deep venous thrombosis, followed by emergency clinician-performed ultrasonography. A whole-leg reference venous ultrasonography was then performed and interpreted separately in the radiology department. Patients were followed for 30 days. The criterion standard for deep venous thrombosis(+), required thrombosis of any leg vein on a reference ultrasonograph and clinical plan to treat. RESULTS We enrolled 183 patients, and 27 (15%) had deep venous thrombosis(+). The sensitivity and specificity emergency clinician-performed ultrasonography was 70% (95% confidence interval [CI] 60% to 80%) and 89% (95% CI 83% to 94%), respectively, with overall diagnostic accuracy of 85% (95% CI 79% to 90%). The posterior probability of deep venous thrombosis(+) among the 88 low-risk patients with a negative emergency clinician-performed ultrasonographic result was 1 of 88, or 1.1% (95% CI 0% to 6%), and the posterior probability of deep venous thrombosis(+) among 14 high-risk patients with a positive emergency clinician-performed ultrasonographic result was 11 of 14, or 79% (95% CI 49% to 95%). CONCLUSION The overall diagnostic accuracy of single-visit emergency clinician-performed ultrasonography performed by a heterogeneous group of ED clinicians is intermediate but may be improved by pretest probability assessment.

Prospective comparative trial of endovaginal sonographic bimanual examination versus traditional digital bimanual examination in nonpregnant women with lower abdominal pain with regard to body mass index classification.

Objective. We hypothesized that a sonographic bimanual examination (SBME) would improve confidence in the pelvic examination in adult nonpregnant women with lower abdominal conditions compared to a traditional digital bimanual examination (DBME). Methods. In a prospective comparative study at an urban regional emergency department, an ultrasound‐trained group of emergency clinicians performed both an SBME and a DBME on 30 women who required a DBME as part of their evaluation. Patients were divided into 3 groups based on their body mass index (BMI) weight class. Inclusion criteria included lower abdominal pain, age between 18 and 55 years, hemodynamic stability, and BMI of greater than 18.5. Exclusion criteria included pregnancy, hysterectomy, oophorectomy, and recent vaginal surgery. The patients sequence of examinations was randomized and then performed by a different member of the study group. Examiners assessed their confidence (0%–100%) in 11 components of the pelvic examination. Results. There were higher scores for the SBME compared to the DBME in the overall composite score, cervical position, uterine size, uterine position, uterine tenderness, ovarian size, ovarian tenderness, and presence of an adnexal mass (P < .05), whereas cervical motion tenderness, cervical os opening, and rectovaginal tenderness did not show significant differences. Across BMI classes, the SBME produced high composite and individual examination scores among all examination criteria. In contrast, the DBME revealed significant differences for uterine size, uterine alignment, uterine tenderness, ovarian size, and ovarian tenderness across BMI classes (P < .05). Conclusions. The SBME provides improved confidence in overall and key aspects of the pelvic examination across BMI classes compared to the DBME.

The Core Content of Clinical Ultrasonography Fellowship Training

The purpose of developing a core content for subspecialty training in clinical ultrasonography (US) is to standardize the education and qualifications required to provide oversight of US training, clinical use, and administration to improve patient care. This core content would be mastered by a fellow as a separate and unique postgraduate training, beyond that obtained during an emergency medicine (EM) residency or during medical school. The core content defines the training parameters, resources, and knowledge of clinical US necessary to direct clinical US divisions within medical specialties. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear in future examinations. This article describes the development of the core content and presents the core content in its entirety.