X. Bobbia

Availability and practice of bedside ultrasonography in emergency rooms and prehospital setting: A French survey

INTRODUCTIONnThe utility of bedside ultrasound (US) performed by emergency physicians has been proven for multiple purposes. There are no data about this technique in emergency departments (ED) in France. The primary objective is to determine the availability of ultrasound device (UD) in EDs and in prehospital settings in France. Minor objectives are to determine the number and type of UD, the most current applications of US and the factors correlated with availability of UDs in the setting of emergency medicine.nnnMETHODSnThis is a cross-sectional, descriptive, multicenter survey from December 2010 to June 2011, including all EDs and prehospital units in France. A questionnaire was sent by e-mail. Non-responders were contacted by telephone with one recall.nnnRESULTSnThe response rate was 74% (327/440) for EDs and 73% (278/379) for prehospital units. A UD is available in 52% (171/327) (CI 95% [46; 58]) of EDs and in 9% (25/278) (CI 95% [5; 13]) of prehospital units. Among departments having no access to UDs, 29% of EDs and 12% of prehospital units have plans to implement emergency physician-performed US. The most common US applications are focused assessment with sonography for trauma and pleural exams.nnnCONCLUSIONnAvailability of UDs in French public hospital EDs is 52% and 9% in prehospital units. Despite the progressive expansion of the technique over the last years, bedside ultrasonography is not yet completely integrated in the physical examination of the patient in an emergency situation in France. A reassessment will be required to confirm the current trend of expansion.

Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France

OBJECTIVEnEnsuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011.nnnMETHODSnWe conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone.nnnRESULTSnThree hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95%xa0CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95%xa0CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS.nnnCONCLUSIONnOur study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Assessment of five different probes for lung ultrasound in critically ill patients: A pilot study

Introduction: The present study was aimed at comparing the diagnosis concordance of five echo probes of lung ultrasound (LUS) with CT scans in intensive care and emergency patients with acute respiratory failure. Materials: This prospective, observational, pilot study involved 10 acute patients in whom a thoracic CT scan was performed. An expert performed an LUS reference exam using five different probes: three probes with a high‐quality conventional echo machine (cardiac phased‐array probe, abdominal convex probe, linear probe) and two probes (cardiac and linear) with a pocket ultrasound device (PUD). Then, a trained physician and a resident performed ‘blinded’ analyses by viewing the video results on a computer. The primary objective was to test concordance between the blinded echo diagnosis and the CT scan. Results: In the 100 LUS performed, the phased‐array probe of the conventional machine and linear array probe of the PUD have the best concordance with the CT scan (Kappa coefficient = 0.75 [CI 95% = 0.54–0.96] and 0.62 [CI 95% = 0.37–0.86], respectively) only for experts and trained physicians. The agreement was always poor for residents. Convex (abdominal) and linear transducers of conventional machines and the phased‐array transducers (cardiac) of PUD have poor or very poor agreement, regardless of the physicians experience. Conclusion: Among the probes tested for LUS in acute patients, the cardiac probe of conventional machines and the linear probes of PUDs provide good diagnosis concordance with CT scans when performed by an expert and trained physician, but not by residents.

Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis

Introduction: Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket‐sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. Materials: This was a prospective, diagnostic test assessment, single‐center study. Patients underwent VCU performed by a trained EP with PUD (CUS‐PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS‐PUDs diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). Results: The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS‐PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS‐PUDs Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. Conclusion: CUS‐PUD performed with a pocket‐sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study

Introduction Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS. Materials Multicentre, prospective, randomized study including emergency physicians and critical care physicians treating ADP on a daily basis. Each participant received three difficult clinical cases of ADP: one with only clinical data (OCD), one with only LUS data (OLD), and one with both. Ultrasound video loops of A, B and C profiles were associated with the cases. Which physician received what data for which clinical case was randomized. Physicians assessed the diagnostic probability from 0 to 10 for each possible diagnosis. The number of uncertain diagnoses (NUD) was the number of diagnoses with a diagnostic probability between 3 and 7, inclusive. Results Seventy‐six physicians responded to the study cases (228 clinical cases resolved). Among the respondents, 28 (37%) were female, 64 (84%) were EPs, and the mean age was 37±8 years. The mean NUDs, respectively, when physicians had OCD, OLD, and both were 2.9±1.8, 2.2±1.7, 2.2±1.8 (p = 0.02). Ultrasound data and ultrasound frequency of use were the only variables related to the NUD. Higher frequency of ultrasound use by physicians decreased the number of uncertain diagnoses in difficult clinical cases with ultrasound data (OLD or associated with clinical data). Conclusion LUS decreases the NUD in ADP. The ultrasound frequency of use decreased the NUD in ADP clinical cases with LUS data.

Intérêt de l’échocardiographie trans thoracique par le médecin urgentiste dans la prise en charge des dyspnée en salle d’accueil des urgences vitales

Introduction La dyspnee est un motif frequent de consultation aux urgences. Le diagnostic etiologique est parfois difficile a poser et le pronostic depend de la rapidite de la mise en place du traitement. L’echographie trans-thoracique (ETT), dont le developpement est en plein essor, devient un outil complementaire a l’examen clinique du medecin urgentiste. Materiel et methodes Cette etude prospective, observationnelle, mono-centrique, realisee en salle d’accueil des urgences vitales (SAUV)xa0d’un centre hospitalo-universitaire, du 1er mars 2013 au 31 juillet 2013 avait pour objectif principal d’evaluerxa0l’interet de l’ETT dans la prise en charge du patient dyspneique en SAUV. Etaient inclus, tous les patients admis en SAUV pour dyspnee aigue, qui beneficiaient d’une ETT realisee par le medecin urgentiste. Resultats Trente-six patients consultant pour dyspnee aigue ont ete inclus, l’âge moyen etait de 80,3xa0±xa09,6xa0ans, L’IGS etait de 26xa0±xa08. Quarante pour cent des medecins urgentistes ont rapporte un interet majeur a la realisation d’une ETT devant une dyspnee, 43xa0% un interet moyen et 17xa0% un faible interet. L’ETT a entraine une modification du diagnostic initial dans 25xa0% des cas et une modification therapeutique dans 47xa0% des cas. Il existe une concordance entre le diagnostic echographique et le diagnostic final dans 92xa0% des cas. Dans 72xa0% des cas l’ETT etait realisee dans la premiere heure suivant l’admission. L’ETT etait realisee sans difficulte majeure dans 69xa0% des cas. Treize medecins ont participe a l’etude, l’âge moyen etait de 35xa0±xa06xa0ans, avec une experience moyenne de 3xa0±xa02xa0ans avec une formation principalement issue du diplome d’etudes specialisees complementaire en medecine d’urgence et de diplomes universitaires. Discussion L’ETT represente un outil majeur dans la prise en charge des dyspnees en SAUV puisqu’elle permet d’optimiser la prise en charge diagnostique et therapeutique tout en restant une technique relativement aisee a acquerir.