Point-of-Care Ultrasound of Post-acute COVID-19 Syndrome: A Prospective Cohort Study.

Introduction Acute COVID-19 patients can suffer from chronic symptoms known as post-acute sequelae of SARS-CoV-2 infection (PASC). Point-of-care ultrasound (POCUS) is established in acute COVID, but its utility in PASC is unclear. We sought to determine the incidence of cardiac and pulmonary abnormalities with POCUS in patients with PASC in a COVID-19 recovery clinic. Methods This prospective cohort study included adults (>18 years old) presenting with cardiopulmonary symptoms to the COVID-19 recovery clinic. A lung ultrasound and standard bedside echocardiogram were performed by ultrasound-trained physicians. Images were interpreted in real time by the performing sonographer and independently by a blinded ultrasound faculty member. Discrepancies in interpretation were addressed by consensus review. A modified Soldati score was calculated by the sum of the scores in each of the 12 lung zones, with each zone score ranging from 0 to 3 (maximum score of 36). The score was then compared to clinical outcomes and outpatient testing.  Results Between April and July 2021, 41 patients received POCUS examinations, with 24 of those included in the study. In all, 15 out of 24 (62.5%) had a normal lung ultrasound. Of the nine subjects with lung abnormalities, the median modified Soldati score was 2. Three patients had trivial pericardial effusions, and all had normal left and right ventricular size and function. Conclusion The majority (62.5%) of patients presenting to the PASC clinic had a normal pulmonary ultrasound, and the vast majority (87.5%) had normal cardiac ultrasounds. These findings suggest that cardiopulmonary symptoms in PASC may be from etiologies not well evaluated by POCUS.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

An Interdisciplinary Approach to the Introduction of Point-of-Care Ultrasound in an Urban Academic Primary Care Center.

Introduction Limited guidance exists for primary and urgent care ultrasound applications. This study sought to identify the most useful applications for providers in these clinical settings, to create and implement a structured interdisciplinary point-of-care ultrasound (POCUS) curriculum, and to assess the effectiveness of the course.  Methods This prospective cohort study took place at an urban academic medical center. After a needs-based assessment of ultrasound applications in primary and urgent care, the Emergency Medicine ultrasound faculty and fellows were paired with a primary or urgent care provider (N = 6). The pairings met for scanning sessions in the emergency department to practice image acquisition, documentation, and incorporation of ultrasound into the workflow. Participants were given POCUS pre-work to review before each session. The final bedside session included a formal Objective Standard Clinical Examination (OSCE) to assess learner proficiency to be cleared for independent imaging. The program was assessed using pre- and post-training surveys.  Results The survey results demonstrated that renal, gallbladder, and soft tissue scans were the most interesting and useful to primary and urgent care providers after completion of the training course.  Conclusion The course was effective, and efficient, simple, high-yield POCUS applications should be included in future programs and organizational guidelines for primary and urgent care POCUS education.

Utilization of Automated Keyword Search to Identify E-Scooter Injuries in the Emergency Department.

Background and objective Accurate identification and categorization of injuries from medical records can be challenging, yet it is important for injury epidemiology and prevention efforts. Coding systems such as the International Classification of Diseases (ICD) have well-known limitations. Utilizing computer-based techniques such as natural language processing (NLP) can help augment the identification and categorization of diseases in electronic health records. We used a Python program to search the text to identify cases of scooter injuries that presented to our emergency department (ED). Materials and methods This retrospective chart review was conducted between March 2017 and June 2019 in a single, urban academic ED with approximately 80,000 annual visits. The physician documentation was stored as combined PDF files by date. A Python program was developed to search the text from 186,987 encounters to find the string "scoot" and to extract the 100 characters before and after the phrase to facilitate a manual review of this subset of charts. Results A total of 890 charts were identified using the Python program, of which 235 (26.4%) were confirmed as e-scooter cases. Patients had an average age of 36 years and 53% were male. In 81.7% of cases, the patients reported a fall from the scooter and only 1.7% reported wearing a helmet during the event. The most commonly injured body areas were the upper extremity (57.9%), head (42.1%), and lower extremity (36.2%). The most frequently consulted specialists were orthopedic and trauma surgeons with 28% of cases requiring a consult. In our population, 9.4% of patients required admission to the hospital. Conclusions The number of results and data returned by the Python program was easy to manage and made it easier to identify charts for abstraction. The charts obtained allowed us to understand the nature and demographics of e-scooter injuries in our ED. E-scooters continue to be a popular mode of transportation, and understanding injury patterns related to them may inform and guide opportunities for policy and prevention.

Point-of-Care Ultrasound in the Diagnosis of an Incarcerated Inguinal Hernia.

Emergency physicians can use point-of-care ultrasound to diagnose inguinal hernias as well as their potential complications, including small bowel obstruction, incarceration, and even strangulation. We provide an overview of the sonographic appearance of inguinal hernias, as well as the diagnostic criteria of serious complications. In this case report, point-of-care ultrasound findings included a non-reducible inguinal hernia associated with significant bowel dilation in multiple loops without signs of intestinal ischemia or necrosis.

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout.

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.

Learner-centered Survey of Point-of-care Ultrasound Training, Competence, and Implementation Barriers in Emergency Medicine Training Programs in India.

BACKGROUND: Point-of-care ultrasound (POCUS) is important to the practice of emergency medicine (EM), but requires training to achieve competence. The purpose of this study was to describe the current state of POCUS practice and perceived barriers to the implementation in EM training programs in India. METHODS: A cross-sectional survey consisting of 28 questions was administered to 378 faculty and residents in postgraduate EM training programs across India. RESULTS: Data were collected from 159 physicians from 16 institutions; 76% of them were EM residents, with a response rate of 42%. Respondents overwhelmingly reported high interest (91%) in learning POCUS topics. Respondents identified highest levels of comfort with the performance and interpretation of trauma ultrasound (US) and echocardiography. Conversely, there was a scarce interest and low levels of competence in performing obstetric US, which may be a result of the practice of triaging these complaints to obstetricians and gynecologists. Lack of US equipment and dedicated training were the highest rated barriers by a significant margin, which 56% of respondents ranked as "very important." CONCLUSIONS: While significant interest in POCUS exists among the Indian EM physicians, comfort and competence were limited to trauma and echocardiography applications. Expansion of and comfort with POCUS use in these settings may be sought through improvement of access to US equipment and a dedicated US curriculum.

Optic Nerve Sheath Diameter Measured by Point-of-Care Ultrasound and MRI.

BACKGROUND AND PURPOSE: Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) and optic nerve diameter (OND) is a method frequently used to screen for an increased intracranial pressure. The aim of this study was to assess the accuracy of US measurements of ONSD and OND, when compared to magnetic resonance imaging (MRI) measurements as the criterion standard. METHODS: In this prospective, single-institution study, orbital US was performed for those patients requiring an emergent brain MRI. ONSD and OND of both eyes were measured in the axial and coronal planes in straight gaze by US. ONSD and OND from brain and orbital MRI were measured by two neuroradiologists. Correlation and agreement between readings were assessed using Pearson's correlations. RESULTS: Eighty-two patients met inclusion criteria. The mean axial and coronal ONSD in the MRI examinations was 5.6 and 5.7 mm at 3-5.9 mm behind the globe, respectively. The mean ONSD from the US measurements was 6.22 and 5.52 mm in the axial and coronal planes, respectively. The mean OND in US examinations was 4.31 mm (axial) and 3.68 mm (coronal). Axial versus coronal measurements of ONSD had a modest correlation in US assessment with an r2 of .385 (P < .001) but there were no correlations between any of the US and MRI measurements. CONCLUSIONS: In measuring ONSD and OND, US measurements showed a modest correlation between axial and coronal measurements, but no concordance was found between US and MRI in our setting.

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound.

Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literature of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support.

Diagnostic Accuracy and Time-Saving Effects of Point-of-Care Ultrasonography in Patients With Small Bowel Obstruction: A Prospective Study.

STUDY OBJECTIVE: We evaluate the accuracy of point-of-care ultrasonography compared with computed tomographic (CT) scan and assess the potential time-saving effect of point-of-care ultrasonography in diagnosing small bowel obstruction. METHODS: This was a prospective observational study of a convenience sample of patients with suspected small bowel obstruction in an academic emergency department (ED). Physician sonographers were blinded to clinical data, laboratory results, and CT scan findings. Point-of-care ultrasonographic findings of small bowel obstruction was the primary outcome, defined as bowel-loop diameter greater than or equal to 25 mm with abnormal peristalsis. Maximum bowel dilatation, visible peristalsis, interluminal free fluid, and bowel wall thickness were evaluated. Time to completion of imaging results was abstracted from the medical records for each imaging modality. RESULTS: The study included 125 patients (median age 54.0 years [interquartile range 43 to 63 years]; 46% men), of whom 32 (25.6%) had small bowel obstruction, and 9 (7.2%) underwent surgery for it. Overall, the sensitivity of point-of-care ultrasonography for small bowel obstruction was 87.5% (95% confidence interval 71.0% to 96.5%), and specificity was 75.3% (95% confidence interval 65.2% to 83.6%). The area under the receiver operating characteristic curve to accurately predict small bowel obstruction was 0.74 (95% confidence interval 0.66 to 0.82). Results were similar across evaluated subgroups, including physician training level. The average time to obtain a CT scan report was 3 hours, 42 minutes; obtaining an abdominal radiograph took 1 hour, 38 minutes; and the mean elapsed time to complete point-of-care ultrasonography was 11 minutes. CONCLUSION: In ED patients with suspected small bowel obstruction, point-of-care ultrasonography has a reasonably high accuracy in diagnosing small bowel obstruction compared with CT scan, and may substantially decrease the time to diagnosis.

Development of a nomogram to predict small bowel obstruction using point-of-care ultrasound in the emergency department.

OBJECTIVE: Early diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis. METHODS: Using data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves. RESULTS: The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03-1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62-25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83-42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44-88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis. CONCLUSION: A unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.

Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.

OBJECTIVES: Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images. METHODS: In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome. RESULTS: A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans. CONCLUSION: Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.

Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda.

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013-2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.

The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department.

STUDY OBJECTIVE: We compare the use and survivorship rate of peripheral intravenous catheters placed in the emergency department (ED) by insertion method. METHODS: We analyzed a prospective cohort of ED patients who received a peripheral intravenous catheter in the ED by ultrasonographically guided or landmark insertion. Research assistants recorded the uses of the ED-inserted catheters during the ED visit and hospitalization. Among subjects admitted, research assistants tracked catheter survivorship for 72 hours or hospital discharge, whichever came first. Research assistants documented reason for catheter removal and whether it was replaced during hospitalization. Premature removal was defined as catheters that were replaced because of mechanical failure, complication, or discomfort. We used multivariate binomial regression to estimate the relative risk of insertion method on premature removal and a Kaplan-Meier curve to compare survivorship duration by insertion method. RESULTS: A cohort of 1,174 patients with a mean age of 45 years and 63% female predominance was analyzed. Catheter use was 73% and 78% in the ED and hospital for the administration of fluids, medications, or contrast agents (and 96% if blood drawn for testing was included). Peripheral intravenous use did not differ significantly in the ED or hospital by insertion method. For 330 patients who were admitted, 132 of 182 patients (73%) in the ultrasonographically guided group and 117 of 148 (79%) in the landmark group had 72-hour catheter survival. Premature removal was not significantly more likely to occur if the catheter was inserted by the ultrasonographically guided method compared with the landmark one (relative risk 1.26; 95% confidence interval 0.88 to 1.80). CONCLUSION: ED-inserted peripheral intravenous catheters were frequently used in the ED and hospital. Peripheral intravenous use and hospital survivorship of ED-inserted peripheral intravenous catheters were similar by insertion method.

Ultrasound-guided intravenous access in adults using SonoStik®, a novel encapsulated sterile guidewire: A prospective cohort trial.

PURPOSE: We evaluated the performance of an encapsulated guidewire designed for single-handed use with ultrasound-guided vascular access (SonoStik) with Seldinger technique, as compared with conventional intravenous catheters placed under ultrasound guidance in healthy subjects. METHODS: This is a prospective cohort trial in healthy subjects in which each subject served as his/her own control by having a SonoStik ultrasound intravenous cannulation placed in one arm and a conventionally placed, standard ultrasound intravenous cannulation placed in the other arm. The basilic vein was used because it is a non-visible and non-palpable vein. Emergency department technicians with extensive experience in ultrasound-guided intravenous access performed the procedures. The first-attempt success rate of intravenous-guided intravenous by using the SonoStik was compared to the standard ultrasound intravenous cannulation in adult healthy subjects. The secondary outcomes including time of procedure, technicians' and subjects' satisfaction, and complications were compared in both arms of the study. RESULTS: A total of 24 volunteers with a mean age of 22.7 years were enrolled. Four emergency department technicians with extensive prior experience with ultrasound-guided intravenous access but with no prior experience using the SonoStik device performed the procedures. The first-attempt success was 83.3% with the use of SonoStik ultrasound intravenous cannulation compared to 95.8% with the standard ultrasound intravenous cannulation. There was a mean of 1.14 insertions per each successful placement in the SonoStik group compared to 1.04 insertions by using the standard catheters (mean differences = -0.1; 95% confidence interval = -0.6 to 0.4). There were no complications in either SonoStik or the standard ultrasound intravenous cannulation group. The mean time of insertion using SonoStik was slightly longer compared to standard ultrasound intravenous cannulation (143.3 vs 109.7 s). CONCLUSION: This study demonstrated that emergency department technicians skilled in ultrasound-guided intravenous access could successfully place SonoStik 83.3% of the time in vessels that were unable to be palpated or visualized. Compared to standard ultrasound intravenous cannulation, the odds ratio of successful cannulation with SonoStik was 0.91 (95% confidence interval = 0.04-17.5). In all cases, the time required to successfully insert SonoStik was less than 4 min from tourniquet application to catheter advancement to hub, with a mean time of less than 2.5 min.

Sonographic localization of a retained urethral foreign body in an elderly patient.

A retained urethral foreign body is an uncommon presentation in the Emergency Department. The diagnosis and treatment of retained urethral foreign bodies are determined by their size, location, shape, and mobility and often require specialty consultation and operative intervention. In this case of a 74-year-old man with a self-inserted, retained urethral foreign body, we present the utility of a bedside ultrasound to detect the depth, size, and distance from the meatus of the object to guide the approach to extraction of the object at the bedside in the Emergency Department. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:296-298, 2018.

Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension.

OBJECTIVE: To assess the impact of an ultrasound hypotension protocol in identifying life-threatening diagnoses that were missed in the initial evaluation of patients with hypotension and shock. METHODS: A subset of cases from a previously published prospective study of hypotensive patients who presented at the Emergency Department in a single, academic tertiary care hospital is described. An ultrasound-trained emergency physician performed an ultrasound on each patient using a standardized hypotension protocol. In each case, the differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. This is a case series of patients with missed diagnoses in whom ultrasound led to a dramatic shift in diagnosis and management by detecting life threatening pathologies. RESULTS: Following a published prospective study of the effect on an ultrasound protocol in 118 hypotensive patients, we identified a series of cases that ultrasound protocol unexpectedly determined serious life threatening diagnoses such as Takotsubo cardiomyopathy, pulmonary embolism, pericardial effusion with tamponade physiology, abdominal aortic aneurysm and perforated viscus resulting in proper diagnoses and management. These hypotensive patients had completely unsuspected but critical diagnoses explaining their hypotension, who in every case had their management altered to target the newly identified life-threatening condition. CONCLUSIONS: A hypotension protocol is an optimal use of ultrasound that exemplifies "right time, right place", and impacts decision-making at the bedside. In cases with undifferentiated hypotension, ultrasound is often the most readily available option to ensure that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential.

Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial.

STUDY OBJECTIVE: Randomized controlled trials report inconsistent findings when comparing the initial success rate of peripheral intravenous cannulation using landmark versus ultrasonography for patients with difficult venous access. We sought to determine which method is superior for patients with varying levels of intravenous access difficulty. METHODS: We conducted a 2-group, parallel, randomized, controlled trial and randomly allocated 1,189 adult emergency department (ED) patients to landmark or ultrasonography, stratified by difficulty of access and operator. ED technicians performed the peripheral intravenous cannulations. Before randomization, technicians classified subjects as difficult, moderately difficult, or easy access according to visible or palpable veins and perception of difficulty with a landmark approach. If the first attempt failed, we randomized subjects a second time. We compared the initial and second-attempt success rates by procedural approach and difficulty of intravenous access, using a generalized linear mixed regression model, adjusted for operator. RESULTS: The 33 participating technicians enrolled a median of 26 subjects (interquartile range 9 to 55). The initial success rate was 81% but varied significantly by technique and difficulty of access. The initial success rate by ultrasonography was higher than landmark for patients with difficult access (48.0 more successes per 100 tries; 95% confidence interval [CI] 35.6 to 60.3) or moderately difficult access (10. 2 more successes per 100 tries; 95% CI 1.7 to 18.7). Among patients with easy access, landmark yielded a higher success rate (10.6 more successes per 100 tries; 95% CI 5.8 to 15.4). The pattern of second-attempt success rates was similar. CONCLUSION: Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access.