JOURNAL CLUB

1/27/2021

Reviewer: Dr. Cameron Shoraka

Topic:

MSK/soft-tissue

Articles:

[1] An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-016-0173-0

Summary: Overview of various POCUS soft tissue applications. Soft tissue infections – identification and drainage of abscesses vs cellulitis vs necrotizing fasciitis; Identification and guided removal of foreign bodies that may be radiolucent – such as wood or plastic; joint effusion and arthrocentesis; long bone fractures; muscle and tendon injury or tears; DVT; Line-placement procedures.

[2] Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis

https://pubmed.ncbi.nlm.nih.gov/27916021/ 7916021/

Summary: Systematic meta-analysis of POCUS for diagnosis of long-bone fractures and post-reduction evaluation. N=3506, wide sensitivity and specificity ranges of 64.7-100% and 79.2%-100%, respectively. Best results found among pediatric forearm and adult ankle fractures. Recommended as an adjunct to radiographs for the evaluation of long bone fractures.

[3] Ultrasound-Guided Gleno-humeral Joint Evaluation and Aspiration

US-Guided Gleno-humeral Joint Evaluation and Aspiration

Summary: Step-by-step guide on how to identify and drain gleno-humeral joint effusion using US guidance. Discussion includes review of shoulder anatomy, primary indication for arthrocentesis – mainly clinical concern for septic joint; pre-procedural planning – including sterile technique and local anesthetic injection; US probe positioning for optimal view and needle guidance.

[4] How to Perform Ultrasound-Guided Knee Arthrocentesis

https://www.acepnow.com/article/how-to-perform-ultrasound-guided-knee-arthrocentesis/

Summary: Step-by-step guide on how to perform US-guided knee arthrocentesis. Discussion includes review of shoulder anatomy, primary indications for arthrocentesis – mainly clinical concern for septic joint; pre-procedural planning – including sterile technique and local anesthetic injection; US probe positioning for optimal view and needle guidance.

2/3/2021

Reviewer: Dr. Cameron Shoraka

Topic:

Resuscitation, shock, dyspnea

Articles:

[1] Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

https://doi.org/10.5811/westjem.2015.11.28525

Summary: Small study (N=57) evaluating improvement of diagnostic accuracy with employment of the “triple scan” (TS). – composed of abbreviated cardiac, lung, and IVC POCUS assessment. Overall accuracy of physician diagnosis improved from 53% to 77% after TS. Limitations: small study, evaluation by verified sonographers separate from primary ER clinician, and final diagnosis based on retrospective chart review.

[2] Basic point-of-care ultrasound framework based on the airway, breathing, and circulation approach for the initial management of shock and dyspnea

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971464/

Summary: Brief review of POCUS in acute care and trauma. Propose framework for POCUS utilization that follows the systematic ABC model typically used in the setting of shock/hypotension and dyspnea. The proposed framework includes POCUS in the evaluation of the airway for tube placement confirmation post-intubation, lung/thoracic evaluation to r/o ptx, pulmonary edema and pleural effusion, and vascular/circulatory evaluation of the heart (focused cardiac US) and IVC, abdomen (evaluation of the aorta, intraabdominal free fluid, hydronephrosis, and cholecystitis), and venous evaluation (DVT evaluation and line placement).

[3] Point of Care Ultrasound: An Overview

Summary: Expert analysis by the American college of cardiology that discussed POCUS in undifferentiated shock, cardiac arrest, trauma, as well as various common clinical presentations – including chest pain, dyspnea, and abdominal pain.

https://pubmed.ncbi.nlm.nih.gov/22795411/​

9/30/2020

Reviewer: Dr. Warren Linnerooth

Summary: This article proposes ED physicians can accurately measure cardiac index, VTI, LVOT by performing bedside focused cardiac ultrasound in the ED. The accuracy of POCUS bedside measurements performed by ED physicians compared favorably to measurements obtained by a certified cardiac sonographer via traditional TTE.

Limitations: Measurement of VTI only practical for patients in which it is possible to obtain a clear apical 5 chamber view with proper alignment of pulse Doppler sample volume, ideally parallel to flow, or within 20-30 degrees of parallel.

Practice Changing? Yes

Take Home Point: For critical-care patients, in which it is possible to obtain a clear apical 5 chamber view, a trained ED physician can measure VTI with an accuracy which compares reasonably with traditional transthoracic echocardiography. Extrapolating: measuring VTI in non-crashing, critical-care patients can provide a useful tool in the ED to trend response to fluids and pressors.

https://pubmed.ncbi.nlm.nih.gov/28460809/

9/23/2020

Reviewer: Dr. Warren Linnerooth

Summary: This study compares compares pain scores, patient satisfaction, complication rates, length of stay for ultrasound-guided interscalene nerve block vs procedural sedation via propofol/fentanyl for anterior shoulder dislocations.

Limitations: Both groups had few significant side effects during their stay in the ED. However, with limited sample size, only 30 patients in each group, and with no long term follow up, the study did not look at the incidence of rare, serious side effects, such as chronic pain from long thoracic nerve damage, dorsal scapular nerve damage. In the operating room, muscle stimulation/twitching is used to identify these structures, which is usually not utilized in the emergency department, which makes identification and avoidance of these structures via US all the more crucial. All of the ED physicians in this study had fairly good experience with US guided nerve blocks, at least 1 per week for 1 year.

Practice Changing? Yes

Take Home Point: The study found decreased length of stay for US guided interscalene block compared to procedural sedation for shoulder dislocation reduction (80.2 vs 108.6 minutes). Subjective pain and satisfaction scores were somewhat worse for for US guided interscalene block vs procedural sedation, although overall, US guided interscalene block was well-tolerated by patients with acceptable patient satisfaction.​

9/2/2020

Reviewer: Dr. Oswald Perkins

Summary: High-frequency linear transducer can improve sensitivity of transabdominal evaluation for intrauterine pregnancy.

Limitations: Transvaginal ultrasound continues to be more sensitive. It also does not provide as comprehensive evaluation of adnexa.

Practice Changing? Yes

Take Home Point: This decreases need for transvaginal ultrasound, expediting evaluation and time to disposition. However, this does not replace transvaginal evaluation I the setting of suspected ectopic.

8/26/2020

Reviewer: Dr. Oswald Perkins

Summary: This article proposes Velocity-Time Integral (VTI) evaluation during cardiac portion of RUSH protocol. VTI measurement is a surrogate measurement for stroke volume that can be trended to evaluate response to fluids or pressors.

Limitations: Although VTI shows great promise, it is unlikely to be implemented to the RUSH protocol and may have a higher role after initial stabilization of patient. This takes time and may distract from resuscitations efforts.

Practice Changing? No

Take Home Point: VTI measurement may have a big role in trending response to fluids and pressors but it is unlikely to be implemented to the cardiac portion of RUSH protocol as it may delay diagnosis and appropriate resuscitative treatment. (ie. Diagnosis of ruptured AAA)

8/20/2020

Reviewer: Dr. Andrea Alvarado

Summary: VExUS seeks to study grading systems to evaluate for venous congestion and predict AKI in patients after cardiac surgery. The overall goal is to develop a grading system to evaluate for venous congestion in patient’s requiring fluid resuscitation. The study found that in patients with a plethoric IVC (>2cm), hepatic, portal and renal vein patterns of venous congestions had a significant association with AKI.

Limitations of this study include that the study population are cardiac surgery patients.

Practice Changing? No.

Take Home Point: While the idea of finding a tool to evaluate for an end-point to fluid resuscitation is important in the ED setting, the study’s patient population is no representative of the ED patient population. Additionally, these views and techniques require an advanced skill level of POCUS.

A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19)

Yi Huang1, Sihan Wang1, Yue Liu1, Yaohui Zhang1, Chuyun Zheng1, Yu Zheng2, Chaoyang Zhang3, Weili

Min4,Huihui Zhou5,Ming Yu5, Mingjun Hu1

https://www.researchsquare.com/article/rs-14928/v1​

05/13/2020

Reviewer: Ludwig Koeneke-Hernandez

Design: Retrospective analysis of 20 patients clinically diagnosed with COVID-19 in Xi'an Hospital had POCUS performed to observe characteristics of pulmonary lesions

Limitations:

Small sample size, single center study

COVID diagnosis based on clinical criteria and not confirmed via laboratory data

Practice Changing? No

Take home point: POCUS can provide reference for the clinical diagnosis and perhaps efficacy of treatment in COVID-19 Patients. US findings include large numbers of B lines, subpleural pulmonary consolidations and poor blood flow in the posterior and inferior areas of the lung.

Diagnostic Accuracy of Ultrasound in the Diagnosis of Small Bowel Obstruction

Stefania Tamburrini 1,* , Marina Lugarà 2, Francesco Iaselli 1, Pietro Paolo Saturnino 1, Carlo Liguori 1, Roberto Carbone 1, Daniela Vecchione 1, Roberta Abete 3, Pasquale Tammaro 3 and Ines Marano

05/13/2020

Article: https://www.ncbi.nlm.nih.gov/pubmed/31390727

Reviewer: Ludwig Koeneke-Hernandez

Design: Retrospective single-center cohort study comparing the accuracy of ultrasound in diagnosing and staging SBO as compared to the gold standard of the CT scan.

Limitations:

Small sample study

Single center study

Practice changing?

Yes

Take home point - Ultrasound is highly accurate in the diagnosis of SBO and improves patient care by decreasing time to diagnosis and expediting consultation and disposition of these potentially rapidly deteriorating patients

Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study

1/21/2020

Reviewer: Dr. Dan Rivera

https://www.ncbi.nlm.nih.gov/pubmed/29175356

Design: Prospective cohort study of patients presenting in cardiac arrest to a single center urban ED from July 2016 to January 2017, using video to determine the time difference for CPR pauses using POCUS and no POCUS

Limitations:

• small sample size, single center study

• applicability to other ERs based on setup

Practice changing? Yes

Take home point: POCUS is associated with extended CPR pauses during cardiac arrest. Using POCUS during cardiac arrest one should be very cognizant of prolonged pauses and institute a set timer to avoid going over 10 seconds.

01/23/2019

Reviewer: Dr. Kristina Jacomino

Article: https://www.jem-journal.com/article/S0736-4679(17)31186-1/fulltext

Prospective diagnostic test assessment of three-point compression ultrasonography performed by ED physicians in a Spanish general district hospital as compared with Doppler US performed by radiology.

Limitations:

• Follow up radiology ultrasound performed after ED visit, unknown how this time lapse affects results

• Majority of patients had BMI >30

• Only experienced, attending physicians participated in the study, limiting generalizability

Practice changing? - Possibly

Take home point – The value of ED performed POCUS DVT studies correlates with experience in compression sonography; therefore, care must be taken to maintain skill and proficiency to use this POCUS modality in clinical decision making.​

01/16/2019

Reviewer: Dr. Kristina Jacomino

Article: https://www.heartandlung.org/article/S0147-9563(18)30228-0/fulltext

Multicenter, randomized pilot trial designed to test a POC lung ultrasound-driven treatment protocol in the ED for pulmonary congestion in acute heart failure against “usual care”.

Limitations:

• Small sample size

• No way to blind the sonographer from the visible clinical status of the patient

Practice changing? - Yes

Take home point – If subsequent studies pan out, standard of care may change to use POC lung ultrasound in the ED to dictate diuresis decisions in those with acute heart failure

12/24/2018

Reviewer: Dr. Tim Montrief

Article: https://www.sciencedirect.com/science/article/pii/S0735675714007190?via%3Dihub

Prospective, observational, single-center cohort study in a large tertiary academic center using a convenience sample of patients in the emergency department who had an above-the-diaphragm central venous catheter placed.

Limitations:

- Small sample size

- Single-site study performed at an academic institution with emergency medicine residents

- Study not powered to look for accuracy, but rather time to complete the study (POCUS vs CXR)

Practice changing? - It depends. In a certain patient population this could be a very useful application of POCUS. In particular, those critically ill patients requiring immediate use of a just-placed central venous catheter.

Take home point – A 2 point ultrasound protocol confirms central line placement and identifies complications more rapidly than standard portable CVXR in a select population of ED patients.

11/30/18

Reviewer: Dr. Paul Eugene

Article: http://www.wjem.com.cn/default/articlef/index/id/648

Retrospective, single-center cohort study in a large tertiary academic center performed to evaluate the accuracy of POCUS compared to abdominal CT in the assessment of patients by a variety of providers with suspected small bowel obstruction.

Limitations:

- Small sample size

- Data was obtained from a retrospective chart review in a single-center cohort

- Providers involved in the study had varied experience levels with point-of-care abdominal ultrasonography and 13% of the ultrasounds performed were deemed "indeterminate" by the performing provider

- Because most of the patients diagnosed in the study site's ED have active cancer, the patient population may not be generalizable to other emergency departments

- Selection bias may have occurred because not every patient with suspected SBO at the site's ED receives abdominal ultrasound prior to CT

- Determination of which patients undergo POCUS is based on several factors including

Practice changing? - It depends. In a certain patient population this could be a very useful application of POCUS. In particular, those patients with a known prior history of small bowel obstruction who have had multiple admissions with subsequent CT scan in the recent past.

Take home point - Ultrasound can play an important role in the identification of SBO in a select population of ED patients.

11/30/18

Reviewer: Dr. Paul Eugene

Article: https://www.sciencedirect.com/science/article/pii/S0735675716302157

Prospective observational study performed in a gross anatomy laboratory on the lower extremities of a single embalmed human cadaver to determine the test characteristics of sonographic detection of FBs and to determine if injecting fluid into the soft tissue in the area of a suspected FB changed these test characteristics.

Limitations:

- Differences in cadaveric and live human tissue may likely resulted in sonographic differences in how the foreign body was depicted in the study

- Postinjection evaluation was performed 1 hour after injection of the foreign body, which was longer than the period for pre injection

- The density of the embalmed tissue may have impeded the distribution of the saline around the foreign body

- Sonographers performed 144 evaluations during the course of the experiment, which may have resulted in improved technique and accuracy over time

- The 2 sonographers had met the ACEP minimum requirements for soft tissue ultrasound and had emergency ultrasound fellowship training so the results may not be applicable to novice soongraphers

Practice changing? - No.

Take home point - There was no statistically significant improvement when hydrodissection was used for foreign body identification in this study.​

11/12/2018

Reviewer: Dr. Paul Eugene

Article : https://doi.org/10.1186/s13089-018-0109-0

Single center double-blinded, cross-sectional, observational study comparing three types of ultrasound transducer in the diagnosis of pneumothorax on lung ultrasound.

Limitations:

- Observers were told that patients would be ventilated similarly and that pneumothorax would be the only pathology (bias)

- Observers could not adjust or change the images by manipulating the probes themselves

- Besides the possibility of pneumothorax, no other clinical parameters were provided to observers

Practice changing? - No.

Take home point - All three transducer types can be used to diagnose pneumothorax but if you want to assess for more than lung pathology, the curvilinear or phased array probe may be more useful.