Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Improves Pain Control in Patients With Rib Fractures.

OBJECTIVES: The serratus anterior plane block (SAPB) is an ultrasound-guided compartment block; limited data suggest that it can decrease pain in patients with rib fractures or chest wall pain. We sought to determine the effect of SAPB on pain and incentive spirometry (IS) maximal vital capacity in adult patients with rib fractures. METHODS: We enrolled a prospective sample of adult patients with at least two unilateral rib fractures who were being admitted for pain control. SAPB was performed by trained emergency physicians. Patients reported pain on an 11-point Numeric Rating Scale at rest and during IS, before, 15, and 60 minutes after SAPB. RESULTS: Mean pain scores decreased by 1.8 (SD 2.17, 95% confidence interval [CI]: 0.79-2.81) at 15 minutes and 2.5 (SD 2.69, 95% CI: 1.24-3.76) at 60 minutes. Compared to pre-block pain scores during IS, mean pain scores decreased by 1.95 (SD 1.99, 95% CI: 1.02-2.88) at 15 minutes and 2.4 (SD 2.42, 95% CI: 1.27-3.53) at 60 minutes. Mean maximum vital capacity increased by 232 mL (SD 406, 95% CI: 36-427) at 60 minutes. Zero SAPB-attributable complications were identified in the 24 hours post-enrollment. CONCLUSIONS: In patients with multiple rib fractures, SAPB reduced pain scores at rest and during IS, and increased maximal vital capacity. The SABP may be a safe and effective modality for pain control in trauma patients with multiple rib fractures.

Bringing anatomy to life: Evaluating a novel ultrasound curriculum in the anatomy laboratory.

As point-of-care ultrasound (POCUS) invades medical specialties, more students covet earlier ultrasound (US) training programs in medical school. Determining the optimal placement and format in the curriculum remains a challenge. This study uses student perceptions and confidence in interpreting and acquiring images to evaluate the effectiveness of an US curriculum and assesses their performance on US content. A unique US curriculum was incorporated into first-year clinical anatomy at Tufts University School of Medicine (TUSM). Students completed surveys evaluating changes in US confidence and perceptions. Mean ratings on pre- and post-surveys were compared using Mann-Whitney U tests. Performance on US examination questions was evaluated. Two independent evaluators coded narrative responses and NVivo software was used to identify common themes. Two hundred eleven students completed the US curriculum. Students reported higher post-curriculum mean confidence ratings on US comprehension, operation, image acquisition, artifact recognition, and normal image interpretation (P < 0.0001). US reinforced anatomy concepts and clinical correlates (9.56, ±0.97 SD; 9.60, ±1.05). Students disagreed with items stating learning US is too difficult (1.2, ±2.2) and that it interferes with learning anatomy (0.68, ±1.7). Students scored above passing on practical US knowledge questions, supporting survey data, and the relation to learning spatial relationships. Qualitative analysis identified seven major themes and additional subthemes. Limited integration of US breaks barriers in students' perceptions and confidence in performing POCUS. The TUSM US curriculum is a natural marriage of anatomy and POCUS applications, serving as a template for medical schools.

WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction.

OBJECTIVE: The ability to identify wall motion abnormalities may be useful for emergency clinicians, but is not typically evaluated in point-of-care echocardiograms. We sought to determine if emergency physicians with basic training in emergency echocardiography could identify regional wall motion abnormalities (RWMA) in patients admitted with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively enrolled patients with admitted with STEMI. Resident physicians with basic training in emergency ultrasound, blinded to other patient data, performed a point-of-care echocardiogram to evaluate for RWMA. If present, they also recorded the suspected territory of the RWMA. We calculated test performance characteristics and compared the agreement between point-of-care and comprehensive echocardiogram for RWMA and territory. RESULTS: 75 patients with STEMI were enrolled, and 62% had a RMWA. RWMA were identified with excellent test performance characteristics (sensitivity 88% (95% CI 75-96); specificity 92% (95% CI 75-99)). There was substantial agreement between the point-of-care echocardiogram and reference standard (K = 0.79; 95% CI: 0.64-0.94). CONCLUSIONS: Emergency physicians with core training in point-of-care echocardiography can accurately identify RMWA.

Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure.

OBJECTIVES: Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used. METHODS: This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). RESULTS: One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP. CONCLUSIONS: Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.