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.
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)
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.
Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study Eben J Clattenburga,∗, Peter Wroea, Stephen Brownb, Kevin Gardnera, Lia Losonczya, Amandeep Singha, Arun Nagdeva,b a Department of Emergency Medicine, Highland Hospital—Alameda
Reviewer: Dr. Dan Rivera
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
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.
Reviewer: Dr. Kristina Jacomino
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”.
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