Critical Ultrasound Journal[JOURNAL]
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167 papers
The evolution of an integrated ultrasound curriculum (iUSC) for medical students: 9-year experience.
Hoppmann RA, Rao VV, Bell F … +49 more , Poston MB, Howe DB, Riffle S, Harris S, Riley R, McMahon C, Wilson LB, Blanck E, Richeson NA, Thomas LK, Hartman C, Neuffer FH, Keisler BD, Sims KM, Garber MD, Shuler CO, Blaivas M, Chillag SA, Wagner M, Barron K, Davis D, Wells JR, Kenney DJ, Hall JW, Bornemann PH, Schrift D, Hunt PS, Owens WB, Smith RS, Jackson AG, Hagon K, Wilson SP, Fowler SD, Catroppo JF, Rizvi AA, Powell CK, Cook T, Brown E, Navarro FA, Thornhill J, Burgis J, Jennings WR, McCallum JB, Nottingham JM, Kreiner J, Haddad R, Augustine JR, Pedigo NW, Catalana PV
Crit Ultrasound J · 2015 Dec · PMID 26589313 · Full text
Interest in ultrasound education in medical schools has increased dramatically in recent years as reflected in a marked increase in publications on the topic and growing attendance at international meetings on ultrasound...
Interest in ultrasound education in medical schools has increased dramatically in recent years as reflected in a marked increase in publications on the topic and growing attendance at international meetings on ultrasound education. In 2006, the University of South Carolina School of Medicine introduced an integrated ultrasound curriculum (iUSC) across all years of medical school. That curriculum has evolved significantly over the 9 years. A review of the curriculum is presented, including curricular content, methods of delivery of the content, student assessment, and program assessment. Lessons learned in implementing and expanding an integrated ultrasound curriculum are also presented as are thoughts on future directions of undergraduate ultrasound education. Ultrasound has proven to be a valuable active learning tool that can serve as a platform for integrating the medical student curriculum across many disciplines and clinical settings. It is also well-suited for a competency-based model of medical education. Students learn ultrasound well and have embraced it as an important component of their education and future practice of medicine. An international consensus conference on ultrasound education is recommended to help define the essential elements of ultrasound education globally to ensure ultrasound is taught and ultimately practiced to its full potential. Ultrasound has the potential to fundamentally change how we teach and practice medicine to the benefit of learners and patients across the globe.
Inferior vena cava diameters and collapsibility index reveal early volume depletion in a blood donor model.
Pasquero P, Albani S, Sitia E … +5 more , Taulaigo AV, Borio L, Berchialla P, Castagno F, Porta M
Crit Ultrasound J · 2015 Dec · PMID 26537114 · Full text
BACKGROUND: Changes of volume status can be readily inferred from variations in diameter of the inferior vena cava (IVC) measured by ultrasound. However the effect of IVC changes following acute blood loss are not fully...
BACKGROUND: Changes of volume status can be readily inferred from variations in diameter of the inferior vena cava (IVC) measured by ultrasound. However the effect of IVC changes following acute blood loss are not fully established. In this study, three different approaches to measuring IVC variables were compared in healthy blood donors, as a model of acute volume depletion, in order to establish their relative ability to detect acute blood loss. METHODS: Inspiratory and expiratory IVC diameters were measured before and after blood donation in hepatic long axis, hepatic short axis and renal short axis views using a 2-5 MHz curvilinear probe. All measurements were recorded and examined in real-time and post-processing sessions. RESULTS: All windows performed satisfactorily but the renal window approach was feasible in only 30 out of 47 subjects. After blood donation, IVC diameters decreased in hepatic long axis, hepatic short axis and renal short axis (expiratory: -19.9, -18.0, -26.5 %; CI 95 %: 14.5-24.1; 13.1-22.9; 16.0-35.9, respectively) (inspiratory: -31.1, -31.6, -36.5 %; CI 95 %: 21.3-40.1; 18.8-45.2; 23.4-46.0, respectively), whereas the IVC collapsibility index increased by 21.6, 22.6 and 19.3 % (CI 95 %: 11.6-42.9; 18.5-39.5; 7.7-30.0). IVC diameters appeared to return to pre-donation values within 20 min but this was only detected by the hepatic long axis view. CONCLUSIONS: IVC diameter and collapsibility index variations, as measured in M mode, consistently detect volume changes after blood donation. The longitudinal mid-hepatic approach performed better by allowing a panoramic view, avoiding anatomical aberrancies at fixed points and permitting to identify the best possible perpendicular plane to the IVC. In addition, it was able to detect time-dependent physiological volume replacement. In contrast, in our hands, the renal window could not be visualized consistently well.
A case of chronic inflammatory demyelinating polyneuropathy with reversible alternating diaphragmatic paralysis: case study.
Haji K, Butler E, Royse C
Crit Ultrasound J · 2015 Dec · PMID 26490681 · Full text
Respiratory failure requiring mechanical ventilation has been reported in patients with bilateral diaphragmatic paralysis due to CIDP. We report a case of CIDP that progressed to respiratory failure with normal chest rad...
Respiratory failure requiring mechanical ventilation has been reported in patients with bilateral diaphragmatic paralysis due to CIDP. We report a case of CIDP that progressed to respiratory failure with normal chest radiography despite unilateral diaphragmatic paralysis. This manifestation would have been missed if ultrasound was not employed.
Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study.
Nazerian P, Tozzetti C, Vanni S … +7 more , Bartolucci M, Gualtieri S, Trausi F, Vittorini M, Catini E, Cibinel GA, Grifoni S
Crit Ultrasound J · 2015 Dec · PMID 26443344 · Full text
BACKGROUND: Pneumoperitoneum is a rare cause of abdominal pain characterized by a high mortality. Ultrasonography (US) can detect free intraperitoneal air; however, its accuracy remains unclear. The aims of this pilot st...
BACKGROUND: Pneumoperitoneum is a rare cause of abdominal pain characterized by a high mortality. Ultrasonography (US) can detect free intraperitoneal air; however, its accuracy remains unclear. The aims of this pilot study were to define the diagnostic performance and the reliability of abdominal US for the diagnosis of pneumoperitoneum. METHODS: This was a prospective observational study. Four senior and two junior physicians were shown, in an unpaired randomized order, abdominal US videos from 11 patients with and 11 patients without pneumoperitoneum. Abdominal US videos were obtained from consecutive patients presenting to ED complaining abdominal pain with the diagnosis of pneumoperitoneum established by CT. Abdominal US was performed according to a standardized protocol that included the following scans: epigastrium, right and left hypochondrium, umbilical area and right hypochondrium with the patient lying on the left flank. We evaluated accuracy, intra- and inter-observer agreement of abdominal US when reviewed by senior physicians. Furthermore, we compared the accuracy of a "2 scan-fast exam" (epigastrium and right hypochondrium) vs the full US examination and the accuracy of physicians expert in US vs nonexpert ones. Finally, accuracy of US was compared with abdominal radiography in patients with available images. RESULTS: Considering senior revision, accuracy of abdominal US was 88.6 % (95 % CI 79.4-92.4 %) with a sensitivity of 95.5 % (95 % CI 86.3-99.2 %) and a specificity of 81.8 % (95 % CI 72.6-85.5 %). Inter- and intra-observer agreement (k) were 0.64 and 0.95, respectively. Accuracy of a "2 scan-fast exam" (87.5 %, 95 % CI 77.9-92.4 %) was similar to global exam. Sensitivity of abdominal radiography (72.2 %, 95 % CI 54.8-85.7 %) was lower than that of abdominal US, while specificity (92.5 %, 95 % CI 79.5-98.3 %) was higher. Accuracy (68.2 %, 95 % CI 51.4-80.9 %) of junior reviewers evaluating US was lower than senior reviewers. CONCLUSIONS: Senior physicians can recognize US signs of pneumoperitoneum with a good accuracy and reliability; sensitivity of US could be superior to abdominal radiography and a 2 fast-scan exam seems as accurate as full abdominal examination. US could be a useful bedside screening test for pneumoperitoneum. Trial registry ClinicalTrials.gov; No.: NCT02004925; URL: http://www.clinicaltrials.gov.
Defining the learning curve of point-of-care ultrasound for confirming endotracheal tube placement by emergency physicians.
Chenkin J, McCartney CJ, Jelic T … +3 more , Romano M, Heslop C, Bandiera G
Crit Ultrasound J · 2015 Dec · PMID 26383011 · Full text
BACKGROUND: Unrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in t...
BACKGROUND: Unrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in the emergency department. Recent studies have demonstrated that point-of-care ultrasound (POCUS) may be a useful adjunct for confirming endotracheal tube placement; however, the amount of practice required to become proficient at this technique is unclear. The purpose of this study is to determine the amount of practice required by emergency physicians to become proficient at interpreting ultrasound video clips of esophageal and endotracheal intubations. METHODS: Emergency physicians and emergency medicine residents completed a baseline interpretation test followed by a 10 min online tutorial. They then interpreted POCUS clips of esophageal and endotracheal intubations in a randomly selected order. If an incorrect response was provided, the participant completed another practice session with feedback. This process continued until they correctly interpreted ten consecutive ultrasound clips. Descriptive statistics were used to summarize the data. RESULTS: Of the 87 eligible physicians, 66 (75.9 %) completed the study. The mean score on the baseline test was 42.9 % (SD 32.7 %). After the tutorial, 90.9 % (60/66) of the participants achieved proficiency after one practice attempt and 100 % achieved proficiency after two practice attempts. Six intubation ultrasound clips were misinterpreted, for a total error rate of 0.9 % (6/684). Overall, the participants had a sensitivity of 98.3 % (95 % CI 96.3-99.4 %) and specificity of 100 % (95 % CI 98.9-100 %) for detecting correct tube location. Scans were interpreted within an average of 4 s (SD 2.9 s) of the intubation. CONCLUSIONS: After a brief online tutorial and only two practice attempts, emergency physicians were able to quickly and accurately interpret ultrasound intubation clips of esophageal and endotracheal intubations.
Point-of-care ultrasonography improves the diagnosis of splenomegaly in hospitalized patients.
Olson AP, Trappey B, Wagner M … +3 more , Newman M, Nixon LJ, Schnobrich D
Crit Ultrasound J · 2015 Dec · PMID 26383010 · Full text
BACKGROUND: It is important to detect splenomegaly as it can have important diagnostic implications. Previous studies, however, have shown that the traditional physical examination is limited in its ability to rule in or...
BACKGROUND: It is important to detect splenomegaly as it can have important diagnostic implications. Previous studies, however, have shown that the traditional physical examination is limited in its ability to rule in or rule out splenomegaly. OBJECTIVE: To determine if performing point-of-care ultrasonography (POCUS) in addition to the traditional physical examination improves the sensitivity and specificity for diagnosing splenomegaly. METHODS: This was a prospective trial of diagnostic accuracy. Physical and sonographic examinations for splenomegaly were performed by students, residents and attending physicians enrolled in an ultrasound training course. Participants received less than 1 h training for ultrasound diagnosis of splenomegaly. The findings were compared to radiographic interpretation of gold standard studies. SETTING/PATIENTS: Hospitalized adult patients at an academic medical center without severe abdominal pain or recent surgery who had abdominal CT, MRI or ultrasound performed within previous 48 h. RESULTS: Thirty-nine subjects were enrolled. Five patients had splenomegaly (12.5 %). The physical examination for splenomegaly had a sensitivity of 40 % (95 % CI 12-77 %) and specificity of 88 % (95 % CI 74-95 %) while physical examination plus POCUS had a sensitivity of 100 % (95 % CI 57-100 %) and specificity of 74 % (95 % CI 57-85 %). Physical examination alone for splenomegaly had an LR+ of 3.4 (95 % CI 0.83-14) and LR- of 0.68 (95 % CI 0.33-1.41); for physical exam plus POCUS the LR+ was 3.8 (2.16-6.62) and LR- was 0. CONCLUSIONS: Point-of-care ultrasonography significantly improves examiners' sensitivity in diagnosing splenomegaly.
Respiratory variation in carotid peak systolic velocity predicts volume responsiveness in mechanically ventilated patients with septic shock: a prospective cohort study.
Ibarra-Estrada MÁ, López-Pulgarín JA, Mijangos-Méndez JC … +2 more , Díaz-Gómez JL, Aguirre-Avalos G
Crit Ultrasound J · 2015 Dec · PMID 26123610 · Full text
BACKGROUND: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity...
BACKGROUND: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. METHODS: We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter. RESULTS: Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77-0.95); followed by stroke volume variation (0.72, 95 % CI 0.63-0.88), passive leg raising (0.69, 95 % CI 0.56-0.80), and pulse pressure variation (0.63, 95 % CI 0.49-0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001). CONCLUSIONS: ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.
Perceived barriers in the use of ultrasound in developing countries.
Shah S, Bellows BA, Adedipe AA … +3 more , Totten JE, Backlund BH, Sajed D
Crit Ultrasound J · 2015 Dec · PMID 26123609 · Full text
BACKGROUND: Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in...
BACKGROUND: Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in developing countries. To further investigate this potential knowledge gap, our primary objective was to assess perceived barriers to ultrasound use in resource-limited settings by surveying care providers who practice in low- and middle-income settings. METHODS: A 25-question online survey was made available to health care providers who work with an ultrasound machine in low- and middle-income countries (LMICs), including doctors, nurses, technicians, and clinical officers. This was a convenience sample obtained from list-serves of ultrasound and radiologic societies. The survey was analyzed, and descriptive results were obtained. RESULTS: One hundred and thirty-eight respondents representing 44 LMICs including countries from the continents of Africa, South America, and Asia completed the survey, with a response rate of 9.6 %. Ninety-one percent of the respondents were doctors, and 9 % were nurses or other providers. Applications for ultrasound were diverse, including obstetrics (75 %), DVT evaluation (51 %), abscess evaluation (54 %), cardiac evaluation (64 %), inferior vena cava (IVC) assessment (49 %), Focused Assessment Sonography for Trauma (FAST) exam (64 %), biliary tree assessment (54 %), and other applications. The respondents identified the following barriers to use of ultrasound: lack of training (60 %), lack of equipment (45 %), ultrasound machine malfunction (37 %), and lack of ultrasound maintenance capability (47 %). Seventy-four percent of the respondents wished to have further training in ultrasound, and 82 % were open to receiving distance learning or telesonography training. Subjects used communication tools including Skype, Dropbox, emailed photos, and picture archiving and communication system (PACS) as ways to communicate and receive feedback on ultrasound images. CONCLUSIONS: Health care providers in the developing world identify lack of training as a primary barrier to regular use of ultrasound in their practice. While equipment requirements including maintenance and cost of machines are also important factors, future research is warranted on best practices for training methods, including telesonography and distance learning to enhance ultrasound use in low-resource settings.
Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured four-view examination.
Arntfield R, Pace J, McLeod S … +3 more , Granton J, Hegazy A, Lingard L
Crit Ultrasound J · 2015 Dec · PMID 26123608 · Full text
BACKGROUND: Transesophageal echocardiography (TEE) offers several advantages over transthoracic echocardiography (TTE). Despite these advantages, use of TEE by emergency physicians (EPs) remains rare, as no focused TEE p...
BACKGROUND: Transesophageal echocardiography (TEE) offers several advantages over transthoracic echocardiography (TTE). Despite these advantages, use of TEE by emergency physicians (EPs) remains rare, as no focused TEE protocol for emergency department (ED) use has been defined nor have methods of training been described. OBJECTIVE: This study aims to develop a focused TEE examination tailored for the ED and to evaluate TEE skill acquisition and retention by TEE-naïve EPs following a focused 4-h curriculum. METHODS: Academic EPs were invited to participate in a 4-h didactic and simulation-based workshop. The seminar emphasized TEE principles and views obtained from four vantage points. Following the training, participants engaged in an assessment of their abilities to carry out a focused TEE on a high-fidelity simulator. A 6-week follow-up session assessed skill retention. RESULTS: Fourteen EPs participated in this study. Immediately following the seminar, 14 (100 %; k = 1.0) and 10 (71.4 %, k = 0.65) successfully obtained an acceptable mid-esophageal four-chamber and mid-esophageal long-axis view. Eleven (78.6 %, k = 1.0) participants were able to successfully obtain an acceptable transgastric short-axis view, and 11 (78.6 %, k = 1.0) EPs successfully obtained a bicaval view. Twelve participants engaged in a 6-week retention assessment, which revealed acceptable images and inter-rater agreement as follows: mid-esophageal four-chamber, 12 (100 %; k = 0.92); mid-esophageal long axis, 12 (100 %, k = 0.67); transgastric short-axis, 11 (91.7 %, k = 1.0); and bicaval view, 11 (91.7 %, k = 1.0). CONCLUSION: This study has illustrated that EPs can successfully perform this focused TEE protocol after a 4-h workshop with retention of these skills at 6 weeks.
Ruptured splenic artery aneurysm detected by emergency ultrasound-a case report.
Lo WL, Mok KL
Crit Ultrasound J · 2015 Dec · PMID 26069053 · Full text
Splenic artery aneurysm is a rare but a potentially fatal condition. It is usually asymptomatic until it ruptures. Here, we present a case of ruptured splenic artery aneurysm in a 59-year-old gentleman presenting with ep...
Splenic artery aneurysm is a rare but a potentially fatal condition. It is usually asymptomatic until it ruptures. Here, we present a case of ruptured splenic artery aneurysm in a 59-year-old gentleman presenting with epigastric pain and hypovolemic shock. The diagnosis was made by emergency ultrasound and CT scan, and he was managed by laparotomy and excision of the splenic artery aneurysm. Priorities in patient management lie in rapid resuscitation, diagnostic imaging, surgical consultation, and subsequent laparotomy. Pitfalls should be borne in mind to differentiate splenic artery aneurysm from abdominal aortic aneurysm when using the emergency ultrasound.
Bedside Doppler ultrasound for the assessment of renal perfusion in the ICU: advantages and limitations of the available techniques.
Schnell D, Darmon M
Crit Ultrasound J · 2015 Dec · PMID 26058500 · Full text
Three Doppler-derived techniques have been proposed to assess renal perfusion at bedside: Doppler-based renal resistive index (RI) which has been extensively but imperfectly studied in assessing renal allograft status an...
Three Doppler-derived techniques have been proposed to assess renal perfusion at bedside: Doppler-based renal resistive index (RI) which has been extensively but imperfectly studied in assessing renal allograft status and changes in renal perfusion in critically ill patients and for predicting the reversibility of an acute kidney injury (AKI), semi-quantitative evaluation of renal perfusion using colour-Doppler which may be easier to perform and may give similar information than RI and contrast-enhanced sonography that may allow more precise renal and cortical perfusion assessment. These promising tools have several obvious advantages including their feasibility, non-invasiveness, repeatability and potential interest in assessing renal function or perfusion. However, several limits need to be taken into account with these techniques, and promising results remain associated with large areas of uncertainty. This editorial will describe more carefully advantages and limits of these techniques and will discuss their potential interest in assessing renal perfusion.
Point-of-care ultrasound in the diagnosis of pulmonary embolism.
Squizzato A, Galli L, Gerdes VE
Crit Ultrasound J · 2015 · PMID 26034556 · Full text
The best diagnostic strategy to confirm or exclude pulmonary embolism (PE) suspicion needs an appropriate combination of clinical assessment, plasma D-dimer measurement, and computed tomographic pulmonary angiography (CT...
The best diagnostic strategy to confirm or exclude pulmonary embolism (PE) suspicion needs an appropriate combination of clinical assessment, plasma D-dimer measurement, and computed tomographic pulmonary angiography (CTPA). CTPA should be used with caution in some patient groups, such as patients with known allergy to contrast media, those with severe renal insufficiency, and pregnant women, and could be not immediately available in case of unstable patients. In the emergency setting, alternative diagnostic strategies should be implemented to overcome CTPA limitations. Ultrasonography is certainly a valuable alternative diagnostic tool. In addition to echocardiography and lower limb compressive venous ultrasonography, lung ultrasound (US) may play an important role in selected patients' subgroups. Recent data on the diagnostic performance of a triple point-of-care US (lung, heart, and leg vein US) are discussed in the present paper, and pros and cons of triple point-of-care US are compared with those of standard diagnostic approaches.
The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock.
Jammal M, Milano P, Cardenas R … +3 more , Mailhot T, Mandavia D, Perera P
Crit Ultrasound J · 2015 · PMID 25995832 · Full text
Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in...
Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in a timely fashion. We present a case of an ill-appearing patient who had an immediate change in management due to the visualization of RHT soon after arrival to the ED. The diagnosis was confirmed after a cardiology-performed ultrasound (US). This case illustrates the value of the recognition of RHT on FocUS and how US protocols designed for the evaluation of shock and shortness of breath may potentially be expanded to patients in a 'compensated' or 'pre-shock' state to expedite the correct diagnosis and to facilitate more timely management.
Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers?
Alzahrani H, Woo MY, Johnson C … +3 more , Pageau P, Millington S, Thiruganasambandamoorthy V
Crit Ultrasound J · 2015 · PMID 25932319 · Full text
BACKGROUND: Aortic stenosis (AS) is a common valve problem that causes significant morbidity and mortality. The goal of this study was to determine whether an emergency physician (EP) could determine severe AS by reviewi...
BACKGROUND: Aortic stenosis (AS) is a common valve problem that causes significant morbidity and mortality. The goal of this study was to determine whether an emergency physician (EP) could determine severe AS by reviewing only two B-mode echocardiographic views (parasternal long axis (PSLA) and parasternal short axis (PSSA)) obtained by trained echocardiographers. METHODS: A convenience sample of 60 patients with no AS, mild/moderate AS or severe AS was selected for health record and echocardiogram review. The echocardiograms were performed in an accredited echocardiography laboratory. An EP blinded to the cardiologist's final report reviewed the PSLA and PSSA views after the cases were randomly sorted. Severe AS was defined as no cusp movement seen by the EP reviewers. A second EP independently reviewed 25% of randomly selected patients for inter-rater reliability. Collected data included patient demographics, EP interpretation and details of each echo view (quality, the number of cusps visualized, presence of calcification) and compared to final cardiology reports. Analyses included descriptive statistics, test characteristics for severe AS and kappa for agreement. RESULTS: The mean age was 75.3 years (range 18 to 90) with 36.7% females. The cardiologist's diagnosis was as follows: 38.3% severe AS, 28.3% mild/moderate AS and 33.3% no AS. The PSSA view was poorer in quality compared with the PSLA (33.3% vs. 13.3%, p = 0.02), but the PSSA view was better than PSLA to visualize all three cusps (83.3% vs. 0%, p = 0.001). There was no difference in the presence of calcification between the mild/moderate and severe AS groups (94.1% vs. 100.0%, p = 0.46). The sensitivity and specificity for EP diagnosis of severe AS was 75.0% (95% CI 56.7% to 85.4%) and 92.5% (83.3% to 97.7%). The kappa for severe AS was 0.69 (0.41 to 0.85), and there was no significant difference between observers in the quality of the view, presence of aortic calcification and the number of cusps visible. CONCLUSIONS: PSLA and PSSA views obtained by trained echocardiographers can be interpreted by an EP with appropriate training to identify severe AS with good specificity. Further larger prospective studies are required before widespread use by EPs.
The risk of cumulative radiation exposure in chest imaging and the advantage of bedside ultrasound.
Gargani L, Picano E
Crit Ultrasound J · 2015 · PMID 25883779 · Full text
The increasing use and complexity of imaging techniques have not been matched by increasing awareness and knowledge by prescribers and practitioners. Imaging examinations that expose to ionizing radiation provide immense...
The increasing use and complexity of imaging techniques have not been matched by increasing awareness and knowledge by prescribers and practitioners. Imaging examinations that expose to ionizing radiation provide immense benefits when appropriate, yet they may result in an increased incidence of radiation-induced cancer in the long-term. The radiation issue is relevant not only for the individual patient but also for the community because small individual risks multiplied by millions of examinations become a significant population risk. As recently highlighted by recent European and American Guidelines, the long-term risk associated with radiation exposure should be considered in the risk-benefit assessment behind appropriate prescription of diagnostic testing.
Point-of-care ultrasound of the diaphragm in a liver transplant patient with acute respiratory failure.
Barbariol F, Vetrugno L, Pompei L … +2 more , De Flaviis A, Rocca GD
Crit Ultrasound J · 2015 · PMID 25859317 · Full text
In some intensive care, nowadays, ultrasound diagnostics have become an extension of the physical examination (like a stethoscope). In this report, we discuss the case of an acute respiratory failure which arose immediat...
In some intensive care, nowadays, ultrasound diagnostics have become an extension of the physical examination (like a stethoscope). In this report, we discuss the case of an acute respiratory failure which arose immediately after the end of general anesthesia. An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound. We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only. To our knowledge, this is the first case report that has shown the usefulness of ultrasonography in detecting diaphragmatic dysfunction as a cause of acute respiratory failure with a subsequent change in patient management. The use of bedside ultrasonography provides practical functional information on the diaphragmatic function in patients with acute respiratory failure and can also be easily repeated if follow-up is required. This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.
Case report: an unrecognized etiology of transient gallbladder pain in heart failure diagnosed with internist-performed point-of-care ultrasound.
Desautels CN, Tierney DM, Rossi F … +1 more , Rosborough TK
Crit Ultrasound J · 2015 · PMID 25852843 · Full text
The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timin...
The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timing of this test in a patient with fluctuating symptoms is not widely recognized as having a significant impact on its sensitivity. However, we present a case report describing the essential role of symptom-timed point-of-care ultrasound in making an elusive diagnosis of transient cholecystalgia in a patient with RUQ pain and congestive heart failure (CHF). This case also demonstrates an important etiology of RUQ pain in patients with CHF beyond that of congestive hepatopathy. A review of the related entities of acalculous cholecystitis, congestive hepatopathy, and diffuse gallbladder wall thickening is provided.
Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents.
Beaulieu Y, Laprise R, Drolet P … +7 more , Thivierge RL, Serri K, Albert M, Lamontagne A, Bélliveau M, Denault AY, Patenaude JV
Crit Ultrasound J · 2015 · PMID 25852842 · Full text
BACKGROUND: Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculu...
BACKGROUND: Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents' proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone. METHODS: Junior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions. RESULTS: After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher's exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher's exact test p = 0.0055). CONCLUSIONS: Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.
10th WINFOCUS World Congress on Ultrasound in Emergency and Critical Care.
Agarwal A, Singh DK, Tripathi M
Crit Ultrasound J · 2015 Mar · PMID 27485907 · Full text
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Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study.
Bhandari T, Socransky SJ
Crit Ultrasound J · 2014 · PMID 25505941 · Full text
BACKGROUND: Carotid ultrasound is performed solely in hospital ultrasound departments or outpatient labs, using both B- and Doppler modes. We hypothesize that B-mode without Doppler can be used to classify patients as ha...
BACKGROUND: Carotid ultrasound is performed solely in hospital ultrasound departments or outpatient labs, using both B- and Doppler modes. We hypothesize that B-mode without Doppler can be used to classify patients as having carotid stenosis (CS) above or below 50%. Our objective is to determine the frequency with which a CS >50% is found using Doppler when no such stenosis was visible using B-mode. METHODS: This was a retrospective study of 100 patients referred to the stroke clinic and 100 patients referred for carotid endarterectomy (CEA). All patients had an elective carotid ultrasound done at Health Sciences North. The ultrasound reports were mixed together and blinded. Investigators determined if there was a CS of greater or less than 50% based on the carotid diagram. These results were compared to the degree of CS found on Doppler. RESULTS: In the CEA group, there were 198 ultrasounds, with 153 showing a CS of >50%. Only one case of CS >50% was missed by B-mode. In the clinic group, 32 of 192 ultrasounds showed a CS of >50%. None were missed by B-mode. B-mode had a sensitivity and negative predictive value of 100% and a specificity of 65%. CONCLUSION: This study supports the theory that it may be possible to use B-mode ultrasound without Doppler to reliably determine if there is CS above or below 50%. Further research is required before carotid ultrasound using B-mode alone can be recommended.
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