A Novel Point-of-care Ultrasound Curriculum for Air Critical Care Personnel.

INTRODUCTION: Point-of care-ultrasound (POCUS) has become ubiquitous in emergency medicine practice for the management of emergent pathophysiology. There is growing interest in its potential as a diagnostic tool in the prehospital setting. Few studies have examined the feasibility or efficacy of curricula targeted at teaching POCUS to prehospital personnel. Our objective in this study was to investigate a curriculum for the extended focused assessment with sonography in trauma (eFAST) exam in helicopter emergency medical services (HEMS) crews. METHODS: This was a pre/post intervention study of HEMS personnel at a tertiary care center. Subjects were administered a pre-intervention written test and an observed structured clinical evaluation (OSCE). Subsequently, they participated in an educational intervention intended to impart proficiency in performing the eFAST. Subjects underwent post-intervention written exams and OSCEs. We analyzed pre- and post-intervention test performance along with the number and quality of practice ultrasound examinations achieved. RESULTS: Sixteen subjects were enrolled (62.5% male, mean age 44.1). After undergoing the intervention, the mean written test score increased 22.1% (t=3.41; P <0.001) and the mean OSCE score increased by 64.5% (t=6.87, P <0.001). All subjects met "passing" criteria for the written test and OSCE on their post-intervention attempt. Subjects accomplished a mean of 21.1 clinically interpretable eFAST sonographs. Most subjects reported the curriculum was useful (90.1%) and that they would incorporate this skill into clinical practice (90.1%). CONCLUSION: A targeted POCUS curriculum was feasible and effective in establishing clinical proficiency in HEMS crews for performing and interpreting the eFAST exam.

Femoral Arterial Doppler Use During Active Cardiopulmonary Resuscitation.

STUDY OBJECTIVE: This study explored femoral arterial Doppler during active cardiopulmonary resuscitation (CPR) to identify and characterize the resumptions of cardiac activity without stopping CPR. METHODS: This was a proof-of-concept study exploring arterial Doppler during cardiac arrest. Patients in cardiac arrest undergoing active CPR were prospectively enrolled. Arterial Doppler of the common femoral artery was recorded during CPR and during pauses in CPR. CPR-induced arterial tracings and native cardiac-induced tracings were analyzed for rate and peak systolic velocity. Cardiac activity on echocardiogram during pause in CPR was classified as "absent," "disorganized," or "organized." Descriptive data and survival are presented as mean and 95% confidence intervals (CI), as well as sensitivity and specificity of Doppler during active CPR in detecting native cardiac pulsations. RESULTS: Sixteen patients with 48 paired Doppler recordings during active CPR, pause in CPR, and associated echocardiogram were enrolled. Native cardiac-induced tracings were visible during 39.6% of pauses in CPR (19 of 48) and during 18.8% of the periods of active CPR (9 of 48). Arterial pulsations were more frequently visualized with organized contractions by echocardiogram (10 of 14, 71%) than disorganized contractions (9 of 22, 41%). Arterial Doppler was 100% specific and 50% sensitive in detecting organized cardiac activity during active CPR. Patients with visible native cardiac pulsations during active CPR demonstrated 0% mortality compared with 67% mortality without visible arterial pulsations. CONCLUSION: Arterial Doppler tracings may identify the resumption of native cardiac activity during active CPR; however, more research is needed.

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy.

BACKGROUND: Recent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest. OBJECTVES: We sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support. METHODS: This was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs). RESULTS: We obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7-14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5-13.5 s) compared with SX (9.3 s, IQR 6.7-15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging. CONCLUSIONS: Echo was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Dengue Management in Triage using Ultrasound in children from Cambodia: a prospective cohort study.

BACKGROUND: Dengue is a mosquito-borne viral infection with increasing global prevalence. It is endemic in more than 100 countries, with a heavy burden in Asia. Ultrasound findings including gallbladder wall thickening, ascites, and pleural effusions secondary to plasma leakage have been described in dengue. We aimed to determine if the presence of point-of-care ultrasound findings early in suspected dengue could predict clinical worsening in ambulatory pediatric patients. METHODS: We did a prospective, single-blinded, observational cohort study at a children's hospital in Siem Reap, Cambodia during periods of dengue outbreak. Ambulatory patients were screened and children ages > 3 month and ≤ 16 years with suspected acute, non-severe dengue were enrolled. Subjects had chest and abdominal ultrasound exams. Independently, subjects were evaluated by a blinded physician who determined a treatment plan as per usual practice. Follow-up was conducted 7-10 days after the initial visit. Analysis of ultrasound findings was performed to determine their relationship with outcome measures including need for unplanned hospital visits or admissions. FINDINGS: A total of 2,186 children were screened during periods of national dengue outbreak in Cambodia in consecutive years 2018-2019, and 253 children met eligibility criteria. Results showed patients with gallbladder wall thickening (> 3·0 mm) who were discharged had a significantly more likely need for unplanned visit or hospitalization than those with normal gallbladder wall, 67% (95% CI 44 - 84) versus 17% (95% CI 12 - 24), p < 0.0001. Subjects with any abnormal ultrasound finding were more likely to be directly admitted versus discharged upon initial presentation, 62·2% (95% CI 46.1 - 76.0) versus 19.5% (95% CI 14.8 - 25.4), p < 0.0001. INTERPRETATION: Point-of-care ultrasound findings, particularly gallbladder wall thickening, in suspected early dengue can help predict disease progression in ambulatory patients. Ultrasound has potential to help guide management of suspected dengue patients and resource management during periods of dengue outbreak. FUNDING: Society for Academic Emergency Medicine Foundation.

Echocardiographic pre-pause imaging and identifying the acoustic window during CPR reduces CPR pause time during ACLS - A prospective Cohort Study.

OBJECTIVES: Pre-pause imaging during cardiopulmonary resuscitation (CPR) involves the acquisition of poor-quality, brief images immediately prior to stopping CPR to allow shorter, better-quality images during the pause. We hypothesize that pre-pause imaging is associated with a decrease in CPR pause length and shorter image acquisition time. METHODS: Prospective, interventional cohort study enrolling out-of-hospital (OOH) cardiac arrest patients. Pre-pause imaging involves pre-localizing of the approximate sonographic window during CPR to support subsequent fine tuning when CPR pauses. Physicians were educated on pre-pause imaging and data was recorded prior- and post- introduction of pre-pause imaging into American cardiac life support (ACLS). Timing of CPR pauses and identification of interventions and events during pause were recorded (e.g., intubation, defibrillation, multiple cardiac ultrasounds). Ultrasound (US) images were reviewed for image quality using a 5-point scale. Primary outcome was length of CPR pause with and without pre-pause imaging. Secondary outcome included US length. RESULTS: One hundred and forty five subjects presenting after OOH cardiac arrest were enrolled over 13 months, 70 during the baseline period prior to pre-pause imaging and 75 after pre-pause imaging was integrated into ACLS. Pre-pause imaging decreased CPR pause length from 28.3 s (95%CI 25.1-31.5) to 12.8 s (95%CI 11.9-13.7). US image acquisition time decreased with pre-pause imaging from 20.4 (95%CI 18.0-22.7) to 11.0 s (95%CI 10.1-11.8). US image quality was unchanged despite the decrease in image acquisition time. (3.0 (95%CI 2.8-3.2) vs 2.7 (95%CI 2.5-2.9)). Multivariate modeling showed that ultrasound did not prolong CPR pause length. CONCLUSION: Pre-pause imaging was associated with significant decrease in CPR pause length and US image acquisition time. Pre-pause imaging should be encouraged for any clinicians who use ultrasound during ACLS.

Development and validation of a novel image quality rating scale for echocardiography during cardiac arrest.

OBJECTIVE: Research into echocardiography (echo) during cardiac arrest has suffered from methodological flaws that limit aggregation of findings. We developed and validated a novel image rating scale for qualitative analysis of echo images obtained during resuscitation. METHODS: A novel 5-point ordinal rating scale was developed and validated using recorded echo images from 145 consecutive cardiac arrest patients. Recorded echo images were reviewed in a blinded fashion by investigators experienced in cardiac arrest echo, and image quality was rated using this scale. Cardiac activity was subsequently classified as no activity, disorganized activity and organized activity. The primary outcome was inter-rater agreement using the image quality rating scale. Secondary outcome was the qualitative evaluation of the type of cardiac activity. RESULTS: A total of 235 ultrasounds were analyzed by study investigators using the image quality rating scale. The overall image quality agreement between reviewers using the scale was good with a weighted kappa of 0.65. Agreement for image quality in subxyphoid images was greater than in parasternal images (0.65-0.52). Echo analysis of cardiac activity showed no activity (33%), disorganized activity (18%), and organized activity (49%). Agreement was great for presence or absence of "cardiac activity" and "organized cardiac activity" with a kappa of 0.84 and 0.78. CONCLUSIONS: A novel image quality rating scale for echo during cardiac arrest demonstrates substantial agreement between reviewers. Agreement regarding the presence or absence, as well as the organization of cardiac activity was substantial.

Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial.

STUDY OBJECTIVE: We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone. METHODS: We performed a prospective randomized clinical trial of patients presenting with a soft tissue abscess at a large, academic emergency department. Patients presenting with an uncomplicated soft tissue abscess requiring incision and drainage were eligible for enrollment and randomized to treatment with or without point-of-care ultrasonography. The diagnosis of an abscess was by physical examination, bedside ultrasonography, or both. Patients randomized to the point-of-care ultrasonography group had an incision and drainage performed with bedside ultrasonographic imaging of the abscess. Patients randomized to the non-point-of-care ultrasonography group had an incision and drainage performed with physical examination alone. Comparison between groups was by comparing means with 95% confidence intervals. The primary outcome was failure of therapy at 10 days, defined as a repeated incision and drainage, following a per-protocol analysis. Multivariate analysis was performed to control for study variables. Our study was designed to detect a clinically important difference between groups, which we defined as a 13% difference. RESULTS: A total of 125 patients were enrolled, 63 randomized to the point-of-care ultrasonography group and 62 to physical examination alone. After loss to follow-up and misallocation, 54 patients in the ultrasonography group and 53 in the physical examination alone group were analyzed. The overall failure rate for all patients enrolled in the study was 10.3%. Patients who were evaluated with ultrasonography were less likely to fail therapy and have repeated incision and drainage, with a difference between groups of 13.3% (95% confidence interval 0.0% to 19.4%). Abscess locations were predominantly torso (21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There was no difference in baseline characteristics between groups relative to abscess size, duration of symptoms before presentation, percentage with cellulitis, and treatment with antibiotics. CONCLUSION: Patients with soft tissue abscesses who were undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure compared with those treated without point-of-care ultrasonography.

Point-of-Care Ultrasound in Trauma.

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Osteoporosis telephonic intervention to improve medication regimen adherence: a large, pragmatic, randomized controlled trial.

BACKGROUND: Multiple studies demonstrate poor adherence to medication regimens prescribed for chronic illnesses, including osteoporosis, but few interventions have been proven to enhance adherence. We examined the effectiveness of a telephone-based counseling program rooted in motivational interviewing to improve adherence to a medication regimen for osteoporosis. METHODS: We conducted a 1-year randomized controlled clinical trial. Participants were recruited from a large pharmacy benefits program for Medicare beneficiaries. All potentially eligible individuals had been newly prescribed a medication for osteoporosis. Consenting participants were randomized to a program of telephone-based counseling (n = 1046) using a motivational interviewing framework or a control group (n = 1041) that received mailed educational materials. Medication regimen adherence was the primary outcome compared across treatment arms and was measured as the median (interquartile range) medication possession ratio, calculated as the ratio of days with filled prescriptions to total days of follow-up. RESULTS: The groups were balanced at baseline, with a mean age of 78 years; 93.8% were female. In an intention-to-treat analysis, median adherence was 49% (interquartile range, 7%-88%) in the intervention arm and 41% (2%-86%) in the control arm (P = .07, Kruskal-Wallis test). There were no differences in self-reported fractures. CONCLUSION: In this randomized controlled trial, we did not find a statistically significant improvement in adherence to an osteoporosis medication regimen using a telephonic motivational interviewing intervention.

Changes in glycosylated hemoglobin after initiation of hydroxychloroquine or methotrexate treatment in diabetes patients with rheumatic diseases.

OBJECTIVE: Prior research demonstrates that hydroxychloroquine (HCQ) lowers glycosylated hemoglobin (HbA(1c) ) in diabetes patients without rheumatic disease. We examined medical records of patients with diabetes mellitus (DM) and concomitant rheumatic illness to measure changes in HbA(1c) after starting HCQ or methotrexate (MTX). METHODS: We used electronic medical records to identify patients beginning treatment with either HCQ or MTX who had a diagnosis of DM (or a pretreatment HbA(1c) value of ≥7%) and at least 1 HbA(1c) measurement both before and within 12 months after initiation of treatment. Using a structured medical record abstraction, we examined rheumatic disease diagnosis, cumulative steroid use, duration (months) between drug initiation and lowest HbA(1c) value, a change in DM medication, body mass index (BMI), age, and sex. Adjusted linear regression models determined changes in HbA(1c) from pretreatment values to the lowest posttreatment values within 12 months. RESULTS: We identified 45 patients taking HCQ and 37 patients taking MTX who met the inclusion criteria. Rheumatoid arthritis had been diagnosed in approximately half of the patients in each group. Age, sex, and mean pretreatment HbA(1c) levels were similar across groups. The mean BMI of those taking HCQ (35.4 kg/m(2) ) was slightly higher than that of those taking MTX (32.2 kg/m(2) ) (P = 0.13). Glucocorticoid use appeared more common in those taking MTX (46%) than in those taking HCQ (29%) (P = 0.17). The mean reduction in HbA(1c) from pretreatment values to the lowest posttreatment values was 0.66% (95% confidence interval [95% CI] 0.26, 1.05) in those taking HCQ compared with 0.11% (95% CI -0.18, 0.40) in those taking MTX. In fully adjusted analyses, the reduction in HbA(1c) among those taking HCQ was 0.54% greater than the reduction among those taking MTX (P = 0.041). CONCLUSION: HCQ initiation was associated with a significantly greater reduction in HbA(1c) as compared with MTX initiation among diabetes patients with rheumatic disease.