Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology

BACKGROUND: To evaluate the utilization of point-of-care ultrasound (POCUS) for the assessment of emergency department (ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED.RESULTS: A total of 264 subjects (92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the final analysis. Most common symptomatic sites were knee (31.8%) and ankle (16.3%). Joint effusion was the most common finding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them (73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients’ medical records.CONCLUSION: Our study findings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.     

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study

BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation.     

Accuracy of bedside ultrasound for the detection of soft tissue foreign bodies by emergency doctors

Objective: To assess the ability of emergency physicians and emergency trainees to detect soft tissue foreign bodies using typical ultrasound equipment. Methods: Following a 20 min interactive training session, emergency physicians and emergency trainees were assessed on ability to identify subcutaneous foreign bodies (wood, glass, plastic, gravel and metal) embedded in an experimental model containing both sham and real entry point incisions. In the second phase of the experiment accuracy of detection of multiple foreign bodies was assessed in a similar sonographic phantom. Results: Six emergency physicians and 14 emergency trainees performed a total of 400 individual sonographic examinations. Emergency physicians correctly identified 29 of 30 foreign bodies and returned sensitivity, specificity, positive predictive value and negative predictive value of 96.7%, 70%, 76.3% and 95.5%, respectively. Trainees correctly identified 60 of 70 foreign bodies and returned sensitivity, specificity, positive predictive value and negative predictive value of 85.7%, 82.9%, 83.3% and 85.3%. Correct identification of the number of foreign bodies present, when multiple, was low (25% physician vs 36% trainee). Conclusion: These data suggest ultrasound in the hands of emergency doctors might be useful as an initial screening tool for detection of soft tissue foreign bodies.     

Top-cited publications on point-of-care ultrasound: The evolution of research trends

Study objectives

Point-of-care ultrasound (POCUS) has been a rapidly growing and broadly used modality in recent decades. The purpose of this study was to determine how POCUS is incorporated into clinical medicine by analyzing trends of use in the published literature.

Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm³ in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN^® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.     

Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis

ObjectiveIt is unclear whether point-of-care ultrasound (POCUS) by emergency medicine physicians is as accurate as radiology-performed ultrasound (RADUS). We aim to summarize the diagnostic accuracy of ultrasonography for intussusception and to compare the performance between POCUS and RADUS.MethodsDatabases were searched from inception through February 2018 using pre-defined index terms. Peer-reviewed primary studies that investigated the diagnostic accuracy of ultrasound for intussusception in children were included. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for intussusception was conducted using the random-effects bivariate model. Subgroup analysis (POCUS vs RADUS) was also performed. Meta-regression was utilized to determine if the diagnostic accuracy between POCUS and RADUS was significantly different.ResultsThirty studies (n = 5249) were included in the meta-analysis. Ultrasonography for intussusception has a sensitivity: 0.98 (95% CI: 0.96–0.98), specificity: 0.98 (95% CI: 0.95–0.99), positive likelihood ratio: 43.8 (95% CI: 18.0–106.7) and negative likelihood ratio: 0.03 (95% CI: 0.02–0.04), with an area under ROC (AUROC) curve of 0.99 (95% CI: 0.98–1.00). Meta-regression suggested no significant difference in the diagnostic accuracy for intussusception between POCUS and RADUS (AUROC: 0.95 vs 1.00, p = 0.128).ConclusionsCurrent evidence suggested POCUS has a high diagnostic accuracy for intussusception not significantly different from that of RADUS.     

Point-of-care ultrasound for the early diagnosis of emphysematous pyelonephritis: A case report and literature review

BACKGROUNDEmphysematous pyelonephritis (EPN) is a rare but fatal necrotic infection of the kidney, which usually leads to septic shock. Therefore, early diagnosis and optimized therapy are of paramount importance. In the past two decades, point-of-care ultrasound (POCUS) has been widely used in clinical practice, especially in emergency and critical care settings, and helps to rapidly identify the source of infection in sepsis. We report a rare case in which a “falls” sign on POCUS played a pivotal role in the early diagnosis of EPN.CASE SUMMARYA 57-year-old man presented with fever and lumbago for 3 d prior to admission. He went to the emergency room, and the initial POCUS detected gas bubbles in the hepatorenal space showing a hyperechoic focus with dirty shadowing and comet-tail artifacts. This imaging feature was like a mini waterfall. His blood and urine culture demonstrated Escherichia coli bacteremia, and EPN associated with septic shock was diagnosed. The patient did not respond to broad-spectrum antibiotic treatment and a perirenal abscess developed. He subsequently underwent computed tomography-guided percutaneous catheter drainage, and fully recovered. We also review the literature on the sonographic features of POCUS in EPN.CONCLUSIONThis case indicates that a “falls” sign on POCUS facilitates the rapid diagnosis of severe EPN at the bedside.     

Handheld ultrasound device for detection of non-opaque and semi-opaque foreign bodies in soft tissues

PURPOSE: The aim of this study was to determine whether a portable handheld ultrasound device can be used to visualize non-opaque and semi-opaque foreign bodies in soft tissues and to characterize their sonographic appearance. METHODS: Twenty-two fragments composed of various natural and man-made materials and ranging from 4 to 20 mm in the maximum longitudinal dimension were embedded into 2 thawed turkey breasts. Two sonographers who were unaware of the number, dimensions, and locations of the fragments used a handheld ultrasound device to detect and characterize the fragments on the basis of their surface echogenicity and acoustic shadowing. The sonographic appearance of each fragment was compared with its actual characteristics. RESULTS: All 22 embedded fragments were successfully identified and localized on sonography. Surface echogenicity and acoustic shadowing varied among the fragments. For some fragments, the sonographically measured maximum longitudinal dimension differed substantially from the actual dimension. CONCLUSIONS: Use of a portable handheld ultrasound device is effective for the detection of foreign bodies with a diameter greater than 4 mm in soft tissues. The sonographic appearances of non-opaque and semi-opaque foreign bodies vary in their patterns of surface echogenicity and acoustic shadowing.     

My patient is injured: identifying foreign bodies with ultrasound

Patients commonly present to the emergency department with a suspected retained foreign body, following penetrating injury. While plain radiography is often the first line in identifying radio-opaque foreign bodies, radiolucent foreign bodies such as wood and plastic can easily be missed. Furthermore, real-time visualization of such a foreign body can assist in its removal. This article evaluates the use of point-of-care ultrasound by emergency physicians in the identification and removal of soft-tissue foreign bodies along with describing the appropriate technique and highlighting the potential pitfalls. An illustrated case example is presented that highlights the benefits of point-of-care ultrasound foreign body detection and guided removal.     

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41–91% and 94–100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50–100% and 93–100%, respectively; for >45 mm ranges were 64–65% and 95–99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.     

Review of simulation model for education of point-of-care ultrasound using easy-to-make tools

Point-of-care ultrasound (POCUS) is a powerful diagnostic tool and provides treatment guidelines in acute critical settings. However, the limitation of using POCUS is operator dependent. Appropriate and validated training for acquiring and using skills in practice must be conducted before using POCUS in clinical settings in order to keep patients safe. Simulation education models have been introduced as a way to solve and overcome these concerns. However, the commercial simulator with sufficiently secured fidelity is expensive and not always available. This review focused on the inexpensive and easily made simulators for education on POCUS in critical specific situations related to the airway, breathing, circulation, and disability. We introduced the simulators that used non-infectious materials, with easily transportable features, and that had a sonographic appearance reproducibility similar to human tissue. We also introduced the recipe of each simulator in two parts: Materials surrounding disease simulators (surrounding materials) and specific disease simulators themselves (target simulators). This review article covered the following: endotracheal or oesophageal intubation, lung (A-lines, B-lines, lung sliding, and pleural effusions such as hemothorax), central vein access, pericardial fluid (cardiac tamponade), the structure related to the eyes, soft tissue abscess, nerve (regional nerve block), and skull fracture simulators.     

Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: a case series

Rapidly determining whether an unresponsive child is in cardiac arrest or in shock, and requiring cardiopulmonary resuscitation can be problematic. The pulse check in children has been shown to be unreliable, not only for laypersons, but also for healthcare providers. The recommendation for checking the pulse in unresponsive children has been eliminated for laypersons in the latest edition of the Emergency Cardiovascular Care guidelines. Thus the decision to initiate cardiopulmonary resuscitation in children, with the goal of delivering effective chest compressions, can be fraught with uncertainty. Despite the use of pediatric advanced life support guidelines developed by the American Heart Association and the American Academy of Pediatrics, management and decision making during resuscitation of children in cardiac arrest can be challenging. Outcomes for out-of-hospital pediatric cardiac arrest remain poor. The decision to end resuscitation in children, often an emotionally charged situation, can also be particularly difficult for physicians. Information from focused point-of-care echocardiography that allows for correlation with the presence or absence of a pulse and real time assessment of resuscitation may help direct and optimize the delivery of resuscitative interventions. We report our preliminary clinical observations of using focused point-of-care echocardiography to correlate with the pulse check during resuscitation in a series of pediatric cardiac arrests.     

Verification of Endotracheal Tube Position by Emergency Nurses Using Ultrasound: A Repeated Measures Cadaver Study

IntroductionEndotracheal intubation is a lifesaving procedure frequently performed in emergency departments. It is associated with some potential risks. Rapid and reliable confirmation of endotracheal tube placement during intubation is critical. Nurses play an important role in the care of patients in various settings. Ultrasound can be performed and interpreted not only by physicians but also by nurses. The aim of this study was to evaluate how well nurses without previous ultrasound experience can determine both esophageal and tracheal localization of endotracheal tubes in cadavers after a short ultrasound training.MethodsThis was a repeated measures study with an educational intervention and no control/contemporaneous comparison group. The study was performed to evaluate the ability of emergency nurses to confirm correct endotracheal tube placement and identify esophageal intubations. A total of 7 emergency nurses were given theoretical education and hands-on training about ultrasound. They diagnosed tracheal or esophageal intubation using ultrasound.ResultsFour cadavers were used 8 times each for the study. A total of 32 intubation procedures were evaluated with ultrasound by each nurse. In the analysis based on 224 responses, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and overall accuracy of ultrasound applied by nurses to detect tracheal intubation were 95.61% (90.06%-98.56%), 97.27% (92.24%-99.43%), 35.06 (11.48-107.10), 0.05 (0.02-0.11), and 96.43% (93.08%-98.45%), respectively. The mean time to evaluate the tube location by ultrasound was 6.57 seconds.DiscussionThe results support that ultrasound can be performed by nurses for the confirmation for esophageal and tracheal intubations quickly and accurately.     

Retention of urethrovesical foreign bodies: case report and literature review

Insertion of foreign bodies into the urethram to obtain sexual pleasure may be complicated by their passage into the urinary bladder along with an inability for the patient to recover the foreign body. We present such a case, review the relevant literature, and discuss Emergency Department (ED) diagnosis and management.     

Ultrasound characteristics of abdominal abscesses involving foreign bodies (gauze).

Three cases of abdominal abscesses involving gauze were studied by B-mode ultrasound. Thick irregular boundary echoes and irregular internal echoes of high amplitude were most characteristic. The ultrasound tomograms are presented, and their characteristics are discussed.     

Delayed cardiac tamponade diagnosed by point-of-care ultrasound in a neonate after peripherally inserted central catheter placement: A case report

BACKGROUNDPeripherally inserted central catheters (PICCs) have been increasingly applied worldwide owing to many advantages. Even with these advantages, the related complications should not be ignored, especially in neonates. The available evidence about PICC-related thrombosis was manifold, but the cardiac tamponade, an emergency and life-threatening complication, has been rarely reported. Early recognized cardiac tamponade by ultrasound may reduce mortality.CASE SUMMARYA neonate weighting 2.8 kg was born at 40 wk of gestation. He was admitted to the Surgery Intensive Care Unit due to suspected congenital megacolon. A PICC line was inserted via the left antecubital fossa for the administration of total parenteral nutrition. Three days later, the patient was still on total parenteral nutrition. Cardiac tamponade caused by PICC was found on ultrasound. The patient recovered spontaneously after an emergency pericardiocentesis.CONCLUSIONProficiency in the use of point-of-care ultrasound may save the life of patients, since it enables clinicians to treat patients faster, more accurately, and in a non-invasive way at the point of care.