Objective Healthcare providers frequently spend excessive time identifying a pulse and have difficulties in precisely verifying its existence. Point-of-care carotid artery ultrasound has been suggested as a potential substitute technique for pulse checks. This study aimed to evaluate the effectiveness of manual pulse checks, 2D carotid ultrasonography (USG), and rapid increases in endtidal carbon dioxide (EtCO2) levels in determining the return of spontaneous circulation (ROSC) in patients who experienced a cardiac arrest in an emergency department (ED).
Methods The study was designed as a single-center, prospective, observational study. Non-traumatic adult patients in cardiopulmonary arrest who were brought to the ED were included. Upon identifying cardiac arrest, the following data were recorded: the initial arrest rhythm, ultrasonographic and manual pulse evaluations, EtCO2 levels, resuscitation period, and vital signs post-ROSC. Team leaders’ judgement used for adjudication of ROSC used as the reference standart.
Results The investigation included 88 patients with a total of 642 CPR cycles administered to who suffered cardiopulmonary arrest. AUC values of the USG, EtCO2 and manual pulse checks were 0.974, 0.802 and 0.862 (p<0.001, p<0.001, p<0.001, respectively). AUC comparisons of USG vs manual pulse check and EtCO2 were significantly different, while manual pulse checks vs EtCO2 had no significant difference (p=0.001, p<0.001, p=0.167, respectively). The sensitivity of bedside USG for detecting carotid pulse was found to be 93.8%, with a specificity of 100%.
Conclusion This study suggests that 2D carotid ultrasonography can be effectively utilized for detecting pulses in patients suffering cardiopulmonary arrest.
Symptomatic urolithiasis is a common cause of emergency department visits, with noncontrast computed tomography considered the imaging gold standard. According to the current guidelines, point-of-care ultrasound (POCUS) is limited to evaluating hydronephrosis as a secondary sign of acute ureteral stones. However, the use of POCUS to detect ureteral stones may lead to decreased radiation to the patient and a more rapid diagnosis. This case series describes 10 patients with suspected symptomatic urolithiasis who were diagnosed accurately by emergency physicians using POCUS to detect obstructive ureteral stones. In three of the cases, POCUS significantly changed the patient’s management. This article also describes the proper techniques for the emergency physician to learn to master POCUS for ureteral stone detection.
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Clin Exp Emerg Med 2023;10(4):363-381. Published online December 29, 2023
Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.
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Objective This study was conducted to evaluate the association between changes in repeated brain computed tomography (CT) findings and the optic nerve sheath diameter (ONSD) determined by ocular ultrasonography in patients with moderate blunt traumatic brain injury (TBI).
Methods This cross-sectional study was performed on patients with moderate blunt TBI (Glasgow Coma Scale, 9–12) who were referred to the emergency department during a 1-year period. Initially, all patients underwent a brain CT scan and primary ocular ultrasonography. Patients who were candidates for a second brain CT scan under observation in the emergency department also underwent a second ocular ultrasound. The primary outcome was the progression of brain lesions on repeated brain CT scans. Logistic regression and the area under receiver operating characteristic curve (AUC) were used.
Results Overall, 204 patients with a mean age of 43±13.4 years were enrolled in the study. The study detected expanding changes in brain CT scans from 29 patients (14.2%). The progression of lesion on CT scan were significantly associated with changes in the Glasgow Coma Scale. In the second brain CT scan, there were significant associations between the progression of lesion on CT scan and the increased size of the ONSD measured on both axial and coronal sections (odds ratio, 17.3–47.5; AUC, 0.88–0.93).
Conclusion Among patients with moderate TBI, an increase in ONSD on ocular ultrasound seems to be an appropriate criterion for repeating a brain CT scan to select a suitable therapeutic intervention.
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Objective Hip fractures are associated with significant morbidity and mortality. Ultrasound-guided peripheral nerve blocks are a safe method to manage pain and decrease opioid usage. The pericapsular nerve group (PENG) block is a novel, potentially superior block because of its motor-sparing effects. Through training, simulation, and supervision, we aim to determine whether it is feasible to perform the PENG block in the emergency department.
Methods Phase 1 consisted of emergency physicians attending a workshop to demonstrate ultrasound proficiency, anatomical understanding, and procedural competency using a low-fidelity model. Phase 2 consisted of a prospective, observational, feasibility study of 10 patients with hip fractures. Pain scores, side effects, and opioid usage data were collected.
Results The median pain score at time 0 (time of block) was 9 (interquartile range [IQR], 6.5–9). The median pain score at 30 minutes was 4 (IQR, 2.0–6.8) and 3.5 (IQR, 1.0–4.8) at 4 hours. All 10 patients required narcotics prior to the initiation of the PENG block with a median dosage of 6.25 morphine milligram equivalents (MME; IQR, 4.25–7.38 MME). After the PENG block, only 30% of the patients required further narcotics with a median dosage of 0 MME (IQR, 0–0.6 MME) until operative fixation.
Conclusion In this feasibility study, PENG blocks were safely administered by trained emergency physicians under supervision. We demonstrated data suggesting a trend of pain relief and decreased opiate requirements, and further investigation is necessary to measure efficacy.
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Point of care ultrasound is an important tool for diagnosis of musculoskeletal and vascular pathology in patients presenting to the emergency department. Superficial vascular and soft tissue structures are well-visualized at the bedside using modern ultrasound systems and have image characteristics that can be rapidly identified. This report describes the use of point of care ultrasound to distinguish between rapidly progressive soft tissue infection and vascular injury following penetrating trauma from a cat scratch. Ultrasound allowed the physician to rapidly make accurate decisions about the next necessary steps in the patient’s care. Point of care ultrasound provides immediate diagnostic information to supplement indeterminate physical examination findings. In this case, it allowed the treating physician to make the diagnosis of arterial injury using ultrasound image characteristics. An integrative approach to ultrasonography of superficial musculoskeletal and vascular structures could enhance clinical decision making and improve care of patients with similar complaints.
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Results There was no difference between the two groups in terms of demographic characteristics. The median (interquartile range) pain scores observed during the procedures were significantly higher in Group PSA than in Group IB (4 [4–6] vs. 2 [0–2], respectively; P<0.001). Patient and operator satisfaction levels were significantly higher in Group IB (P<0.001). Oxygen desaturation was statistically higher in Group PSA than in Group IB (40.00% vs. 3.33%, respectively; P=0.002).
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Objective Smart glasses can provide sonographers with real-time ultrasound images. In the present study, we aimed to evaluate the utility of smart-glasses for ultrasound-guided peripheral venous access.
Methods In this randomized, crossover-design, simulation study, 12 participants were recruited from the emergency department residents at a university hospital. Each participant attempted ultrasound-guided peripheral venous access on a pediatric phantom at intervals of 5 days with (glasses group) or without (non-glasses group) the use of smart glasses. In the glasses group, participants confirmed the ultrasound image through the lens of the smart glasses. In the non-glasses group, participants confirmed the ultrasound image through the display viewer located next to the phantom. Procedure time was regarded as the primary outcome, while secondary outcomes included the number of head movements for the participant, number of skin punctures, number of needle redirections, and subjective difficulty.
Results No significant differences in procedural time were observed between the groups (non-glasses group: median time, 15.5 seconds; interquartile range [IQR], 10.3 to 27.3 seconds; glasses group: median time, 19.0 seconds; IQR, 14.3 to 39.3 seconds; P=0.58). The number of head movements was lower in the glasses group than in the non-glasses group (glasses group: median, 0; IQR, 0 to 0; non-glasses group: median, 4; IQR, 3 to 5; P<0.01). No significant differences in the number of skin punctures or needle restrictions were observed between the groups.
Conclusion Our results indicate that smart-glasses may aid in ensuring ultrasound-guided peripheral venous access by reducing head movements.
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Objective The point-of-care ultrasound of the airway (POCUS-A) is a useful examination method but there are currently no educational programs for medical students regarding it. We designed a POCUS-A training curriculum for medical students to improve three cognitive and psychomotor learning domains: knowledge of POCUS-A, image acquisition, and image interpretation.
Methods Two hours of training were provided to 52 medical students in their emergency medicine (EM) rotation. Students were evaluated for cognitive and psychomotor skills before and immediately after the training. The validity measures were established with the help of six specialists and eight EM residents. A survey was administered following the curriculum.
Results Cognitive skill significantly improved after the training (38.7±12.4 vs. 91.2±7.7) and there was no significant difference between medical students and EM residents in posttest scores (91.2±7.7 vs. 90.8±4.6). The success rate of overall POCUS-A performance was 95.8%. The students were confident to perform POCUS-A on an actual patient and strongly agreed to incorporate POCUS-A training in their medical school curriculum.
Conclusion Cognitive and psychomotor skills of POCUS-A among medical students can be improved via a limited curriculum on EM rotation.
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Objective To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization.
Methods We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR.
Results Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (P<0.001).
Conclusion Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.
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A previously healthy 1-year-old boy suddenly began coughing while eating a dried sweet potato. Because he continued gagging after vomiting a piece of the dried sweet potato, his mother brought him to our emergency room. Upon arrival, despite normal pulmonary findings, he was drooling and gagging. Ultrasonography was performed because food impaction at the upper esophagus was suspected based on his medical history and physical examination, and results showed that a linear hyperechoic lesion was obstructing the posterior esophageal wall. Computed tomography was also considered for a detailed examination of the foreign body. However, the patient vomited the dried sweet potato before the test was performed. After vomiting the foreign body, the patient stopped gagging, and his ultrasonographic findings were normal. Therefore, the patient was discharged without any complications.
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Objective Our objective was to determine the utility of point-of-care ultrasound (POCUS) to identify and guide treatment of tamponade or clinically significant pericardial effusions in the emergency department (ED). Methods This was a retrospective cohort study of non-trauma patients who were diagnosed with large pericardial effusions or tamponade by the ED physician using POCUS. The control group was composed of those patients later diagnosed on the medical wards or incidentally in the ED by other means such as a computed tomography. The following data were abstracted from the patient’s file: demographics, medical background, electrocardiogram results, chest radiograph readings, echocardiogram results, and patient outcomes. Results There were 18 patients in the POCUS arm and 55 in the control group. The POCUS arm had a decreased time to pericardiocentesis (11.3 vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days, P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL, P=0.139) in the group diagnosed by POCUS. Conclusion This study suggests that POCUS may effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay. Pericardial tamponade or a large pericardial effusion should be considered in all patients presenting to the ED with clinical, radiographic, or electrocardiographic signs of cardiovascular compromise.
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Traumatic or spontaneous hemarthroses are an important cause of joint effusions, and can complicate innate or acquired coagulopathies. The elbow is an unusual location for a spontaneous hemarthrosis; we describe a previously unreported case of warfarin-induced spontaneous elbow hemarthrosis, diagnosed by point-of-care ultrasound. On the basis of clinical and ultrasound findings arthrocentesis was deferred, and the patient was successfully treated with warfarin reversal and conservative care. Physical examination is unreliable for the detection of a joint effusion, and misdiagnosis and can lead to unnecessary investigation or resource use. Point-of-care ultrasound allows accurate, prompt, direct visualization of a joint effusion, and non-invasive confirmation of a hemarthrosis. Ultrasound can facilitate accurate diagnosis and characterization of joint effusions to improve the care of patients with coagulopathy.
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Objective The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay.
Methods A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit.
Results A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000).
Conclusion The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.
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Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial Andre Kumar, Yingjie Wang, Jason Bentley, Libo Wang, Jason Bentley, Marta Almli, Jason Horn, Ronald Witteles, Neera Ahuja, John Kugler Journal of Hospital Medicine.2020; (Volume 15,): 154. CrossRef
Prevalence of microhematuria in renal colic and urolithiasis: a systematic review and meta-analysis Bruno Minotti, Giorgio Treglia, Mariarosa Pascale, Samuele Ceruti, Laura Cantini, Luciano Anselmi, Andrea Saporito BMC Urology.2020;[Epub] CrossRef
Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel‐Group Randomized Trial Andre Kumar, Yingjie Weng, Jason Bentley, Marta Almli, Jason Hom, Ronald Witteles, Neera Ahuja, John Kugler Journal of Hospital Medicine.2020; 15(3): 154. CrossRef
Aktualisierung der S2k-Leitlinie zur Diagnostik, Therapie und Metaphylaxe der Urolithiasis (AWMF Registernummer 043-025) C. Seitz, T. Bach, M. Bader, W. Berg, T. Knoll, A. Neisius, C. Netsch, M. Nothacker, S. Schmidt, M. Schönthaler, R. Siener, R. Stein, M. Straub, W. Strohmaier, C. Türk, B. Volkmer Der Urologe.2019; 58(11): 1304. CrossRef
Using point-of-care ultrasound Michael Breunig, Deanne Kashiwagi JAAPA.2019; 32(2): 44. CrossRef
Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study Seok Goo Kim, Ik Joon Jo, Taerim Kim, Sung Yeon Hwang, Joo Hyun Park, Tae Gun Shin, Min Seob Sim, Won Chul Cha, Hee Yoon Medicina.2019; 55(11): 717. CrossRef
Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations Bjarte Sorensen, Steinar Hunskaar The Ultrasound Journal.2019;[Epub] CrossRef
The Role of Technology in the Bedside Encounter Andre Kumar, Gigi Liu, Jeff Chi, John Kugler Medical Clinics of North America.2018; 102(3): 443. CrossRef
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