Trends in Point of Care Ultrasound Familiarity Among Undergraduate Medical Clerkship Educators.

OBJECTIVES: Despite growing use of point of care ultrasound (POCUS), there remains a paucity of data about familiarity with POCUS among educators who dictate curricular content in undergraduate medical education. This paper aims to longitudinally characterize the level of comfort and frequency of POCUS use among faculty involved in undergraduate clerkship education. METHODS: A web-based cross-sectional survey assessing comfort, frequency of use, and awareness of indications for POCUS among faculty involved in Internal Medicine, Family Medicine, and Surgery undergraduate clerkship education in a single urban academic medical center in 2016 and again in 2022. RESULTS: A total of 45 responses from 2016 and 30 responses from 2022 are included. The percentage of faculty "not comfortable" with performing POCUS decreased from 78% to 46%, although the overall change in comfort was not statistically significant. Comfort interpreting POCUS images, frequency of POCUS use, and familiarity with the clinical applications of POCUS all improved. Faculty identified multiple barriers to more frequent POCUS use. CONCLUSIONS: Over a six-year period at one urban, academic medical center, comfort with POCUS and frequency of use have increased slightly but remain low among core faculty responsible for clerkship education. There are still large gaps in knowledge and very few faculty regularly use POCUS, which can be attributed to multiple different barriers.

Hematometra: A Rare Case of Pelvic Pain in Females Identified with Point of Care Ultrasound.

The differential diagnosis for abdominal or pelvic pain in women of child-bearing age that present to the emergency department is broad. A rare cause of abdominal and pelvic pain is hematometra, or a collection of blood products within the uterus. While blood is normally expelled through menses, this process is disrupted in some patients due to congenital or acquired abnormalities. This can lead to progressive uterine distension and pain, which may ultimately require medical or surgical intervention. Hematometra is rare, but is a serious condition that can be diagnosed easily at bedside using point of care ultrasound.

Training, Competency, and Interdisciplinary Collaboration in Point-of-Care Ultrasound.

Point-of-care ultrasound can provide critical diagnostic information and add to procedural safety. As with any clinical skill, however, it must be applied by an adequately trained provider, with systems to ensure safety. Training can include a mix of hands-on training with traditional didactics, online coursework, and simulation, but each carries its own costs and benefits worth of review. Following training it is essential to think about assessment of competency in point-of-care ultrasound to reflect the combination of cognitive and procedural skills that makes up the practice. Within the frameworks described, expansion can be expected across specialty and professional boundaries.

Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education.

OBJECTIVES: A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships. METHODS: The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation. RESULTS: One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001). CONCLUSIONS: Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

Transesophageal echocardiography (TEE)-guided transvenous pacing (TVP) in emergency department.

BACKGROUND: Placement of a temporary pacemaker is a vital skill in the emergency setting in patients that present with life-threatening bradycardia. Transvenous pacing is the definitive method of stabilizing the arrhythmia compared to transcutaneous pacing, as it provides more comfort and better control of heart rate, until the insertion of a permanent pacemaker. CASE REPORT: In this case report, we describe the steps using TEE to guide the insertion of transvenous pacer at the emergency department. Traditionally, the process of floating a transvenous pacer wire is performed "blindly" using landmarks and a monitoring ECG finding for capture, or under transthoracic echocardiography (TTE) ultrasound guidance. The blind procedure is associated with higher rate of failure and complications. While guidance using TTE is associated with higher success rates and fewer complications, inadequate imaging of the right side of the heart may limit the utility of this imaging modality. The use of transesophageal echocardiography (TEE) by emergency medicine and critical care physicians has gained traction in recent years due to its clear images and lack of interference with procedures being performed on the chest. In this article, we describe a protocol using TEE to guide the insertion of transvenous pacer through a case illustration.

Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography.

BACKGROUND: Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor. CASE SUMMARY: A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief. DISCUSSION: This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.

Diagnosis of Renal Artery Aneurysm by Point-of-Care Ultrasound in the Emergency Department: A Case Report and Brief Review of the Literature.

BACKGROUND: Renal artery aneurysm (RAA) is defined as a focal dilatation of ≥50% of the adjacent, disease-free artery. Although typically asymptomatic, RAA can lead to hypertension, hematuria, and rupture. The risk of rupture is higher in pregnant patients and may result in the death of the mother and the fetus. We describe a case of RAA discovered on point-of-care ultrasound (POCUS) in the emergency department. CASE REPORT: A 46-year-old woman with no medical history presented to the emergency department with lower abdominal pain, vomiting, diarrhea, and increased urination. POCUS was performed to evaluate the cause of the patient's symptoms. This study revealed a 2.40 cm × 3.65 cm aneurysm in the right kidney. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rupture of RAA occurs in 3% to 5% of cases. Mortality to both the mother and the fetus is particularly high in gravid patients. RAA may be mistaken for other renal entities such as prominent renal veins or hydronephrosis. Properly identifying this pathology via POCUS can lead to early intervention. © 2022 Elsevier Inc.

Worsening cardiac tamponade after pericardiocentesis in a patient with anterior mediastinum mass: a case report.

Background: Mediastinal mass is an entity with variable pathology and clinical spectrum. Anterior mediastinal mass can result in severe symptoms due to involvement of surrounding vital structures such as the great vessels, trachea-bronchial tree, and heart. We highlight a case of cardiac tamponade in a patient with an anterior mediastinal mass that was paradoxically worsened after decompressive pericardiocentesis. Case summary: A 21-year-old male presented to the emergency department (ED) with breathlessness and hypotension. Bedside focused cardiac ultrasound revealed cardiac tamponade which was made worse with an anterior mediastinal mass compressing the right heart chambers. The patient was intubated for respiratory failure, following which an ultrasound-guided pericardiocentesis was performed. Unexpectedly, his hemodynamic status worsened after aspiration of 1000 mL of pericardial fluid. A repeat focused cardiac ultrasound showed reduced pericardial effusion, but worsening of right heart chambers compression by the mediastinal mass. Re-expansion of the pericardium space with 600 mL of normal saline improved the patient's vital signs, and reduced the right heart compression. Computed tomography was deferred due to the patient's hemodynamic instability. Despite resuscitation with fluids and initiation of vasopressor, the patient's condition deteriorated. He succumbed to his illness due to obstructive shock causing multi-organ failure. The autopsy showed a large anterior mediastinal mass, and histopathological examination confirmed the diagnosis of lymphoma. Discussion: This case demonstrated the therapeutic challenges of managing a shock patient with anterior mediastinal mass, and massive pericardial effusion causing cardiac tamponade.

Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols.

RATIONALE & OBJECTIVE: Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED: 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME: Prediction of pulmonary congestion and 30-day mortality. RESULTS: All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS: Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS: Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

Lung Ultrasound Imaging: A Primer for Echocardiographers.

Lung ultrasound (LUS) has gained considerable acceptance in emergency and critical care medicine but is yet to be fully implemented in cardiology. Standard imaging protocols for LUS in acute care settings have allowed the rapid and accurate diagnosis of dyspnea, respiratory failure, and shock. LUS is greatly additive to echocardiography and is superior to auscultation and chest radiography, particularly when the diagnosis of acute decompensated heart failure is in question. In this review, the authors describe LUS techniques, interpretation, and clinical applications, with the goal of informing cardiologists on the imaging modality. Additionally, the authors review LUS findings associated with various disease states most relevant to cardiac care. Although there is extensive literature on LUS in the acute care setting, there is a dearth of reviews directly focused for practicing cardiologists. Current evidence demonstrates that this modality is an important adjunct to echocardiography, providing valuable clinical information at the bedside.

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest.

BACKGROUND: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA. MATERIALS AND METHODS: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation. RESULTS: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration. CONCLUSIONS: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade.

BACKGROUND: Pericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management. CASE PRESENTATION: We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients. CONCLUSIONS: Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Shock due to superior vena cava obstruction detected with point of care ultrasound.

Superior Vena Cava (SVC) syndrome is caused by SVC obstruction by external compression or intraluminal thrombus. Patients with the condition can present with upper body swelling, shortness of breath and shock. This case report highlights the use of point-of-care ultrasound (POCUS) to evaluate a patient with SVC syndrome in the emergency department. The test offers many advantages over computed tomography (CT), venography, and magnetic resonance imaging which are limited in hemodynamically unstable patients. A 60-year-old male presented with acute respiratory distress and shock. The POCUS showed the presence of a right lung consolidation and SVC thrombus. CT revealed the presence of a large mediastinal mass causing compression of the SVC with clot seen inside the vessel. The patient was thrombolysed with intravenous streptokinase and his hemodynamics improved. Further investigation confirmed the diagnosis of lymphoma. The SVC can be visualized with transthoracic echocardiography using either the suprasternal, right supraclavicular or right parasternal approach. In this case, the presence of consolidation of the right lung mass provided an acoustic window for the visualization of the SVC using the right parasternal view, thereby allowing for more rapid diagnosis and management.

Assessing Competence in Critical Care Echocardiography: Development and Initial Results of an Examination and Certification Processes.

OBJECTIVES: To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography. DESIGN: A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria. SETTING: The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA. SUBJECTS: Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM). MEASUREMENTS AND MAIN RESULTS: A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%). CONCLUSIONS: The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.

Pericardial decompression syndrome: A complication of pericardiocentesis.

Pericardial Decompression Syndrome (PDS) is an uncommon but life-threatening complication following pericardiocentesis for cardiac tamponade. We report PDS after pericardiocentesis in two patients that presented to the emergency department with cardiac tamponade. In both cases, pericardiocentesis was performed under ultrasound guidance using the left parasternal approach and approximately 1200-1500 mL of pericardial fluid was removed. Immediately after pericardiocentesis, the haemodynamic status of the patients improved. However, 2-3 h post decompression, both patients developed hypotension and pulmonary edema with reduced left ventricular function, suggestive of PDS. PDS is a condition that is described as paradoxical worsening of vital signs after successful decompression of the pericardium in the setting of acute tamponade. Three possible mechanisms explaining PDS are ischaemic, hemodynamic and autonomic processes. If PDS is unrecognized and untreated, it is associated with a high mortality rate secondary to pulmonary edema and cardiogenic shock. If managed urgently, the cardiopulmonary dysfunction in PDS is usually transient and largely reversible with supportive care.