Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine.

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study.

It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.

Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department.

Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.

Emergency Point-of-Care Ultrasound Stewardship - A Joint Position Paper by EuSEM and EFSUMB and Endorsed by IFEM and WFUMB.

Emergency Medicine Point-of-Care Ultrasound (EMPoCUS) is a convincing concept. It has spread rapidly because of its intuitive, simple applicability and low equipment costs. The speed of its emerging growth frequently outpaces the development of quality assurance and education. Indeed, education standards vary worldwide, and in some cases seem to neglect the principles of modern competence-based education. Additional challenges are encountered such as remote or low resource medical practice. Here, EMPoCUS might be the only ad-hoc imaging modality available. Once mastery of EMPoCUS is achieved, emergency physicians should be able to independently and efficiently care for their patients using a variety of PoCUS skills. However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational milestones. This threatens to take quality assurance down the wrong path. It created a scenario in which concrete EMPoCUS skill outcome measures that would realistically reflect the training objectives and simultaneously would be easily observable and verifiable are lacking. In view of the dangers of poorly controlled EMPoCUS dissemination and the current lack of European guidelines, we would like to set central standards for European EMPoCUS stewardship based on a critical review of the current situation. This position paper, which was jointly developed by EuSEM and EFSUMB and endorsed by IFEM and WFUMB, is also intended to accompany the EFSUMB/EuSEM guidelines on PoCUS currently being prepared for publication.

Pulmonary Findings in Hospitalized COVID-19 Patients Assessed by Lung Ultrasonography (LUS) - A Prospective Registry Study.

PURPOSE: This prospective two-centre study investigated localisation-dependent lesion patterns in COVID-19 with standard lung ultrasonography (LUS) and their relationship with thoracic computed tomography (CT) and clinical parameters. MATERIALS AND METHODS: Between April 2020 and April 2021, 52 SARS-CoV-2-positive patients in two hospitals were examined by means of LUS for "B-lines", fragmented pleura, consolidation and air bronchogram in 12 lung regions and for pleural effusions. A newly developed LUS score based on the number of features present was correlated with clinical parameters (respiration, laboratory parameters) and the CT and analysed with respect to the 30- and 60-day outcome. All patients were offered an outpatient LUS follow-up. RESULTS: The LUS and CT showed a bilateral, partially posteriorly accentuated lesion distribution pattern. 294/323 (91%) of CT-detected lesions were pleural. The LUS score showed an association with respiratory status and C-reactive protein; the correlation with the CT score was weak (Spearman's rho = 0.339, p < 0.001). High LUS scores on admission were also observed in patients who were discharged within 30 days. LUS during follow-up showed predominantly declining LUS scores. CONCLUSION: The LUS score reflected the clinical condition of the patients. No conclusion could be made on the prognostic value of the LUS, because of the low event rate. The LUS and CT score showed no sufficient correlation. This is probably due to different physical principles, which is why LUS could be of complementary value.

Electrocardiographic alterations by pneumothorax: a case-control study with review of the literature.

BACKGROUND: Numerous ECG alterations due to pneumothorax have been reported. The objective of the study was to establish the presence of ECG changes associated with pneumothorax in the literature, and in a cohort of patients with proven pneumothorax compared with age- and sex-matched healthy controls. METHODS: A systematic review for ECG alterations associated with pneumothorax was performed. We then reviewed our hospital database for patients with pneumothorax and identified all patients with an ECG available at this time. The retrieved ECG alterations in the systematic review were identified in our pneumothorax patients and compared with a healthy sex- and age-matched control group. Accordingly, we calculated sensitivity and specificity for all alterations. RESULTS: Seventeen ECG alterations were found and defined from the systematic review. Our pneumothorax cohort consisted of 82 pneumothorax patients and 82 control patients. Specificity was mostly more than 90%, but sensitivities were low. Phasic R voltage (pneumothorax group 25.6% vs control group 1.2%), T-wave inversion (31.7% vs 2.4%), prolonged QTc (11.0% vs 2.4%), right axis deviation (14.6% vs 3.6%) and QRS voltage ratio in aVF/I >2 (41.5% vs 22.0%) were significantly more frequent in pneumothorax patients compared with controls. CONCLUSION: The sensitivity of published ECG signs in predicting pneumothorax in our cohort was low, which means that ECG findings are an unsuitable tool for pneumothorax screening. However, presence of these ECG signs might raise a suspicion of pneumothorax in patients presenting with dyspnoea, or unclear chest discomfort.

[CME Sonography 100/Answers: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System]. / CME-Sonografie 100/Antworten: Notfallsonografie der Weichteile und des Bewegungsapparats.

CME Sonography 100/Answers: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System Abstract. The term "emergency sonography" refers to a focused sonography in emergency situations, also called emergency "Point of Care Ultrasound (POCUS)". The attending physician applies it specifically and directly on the patient. As an indispensable part of the physical examination, emergency ultrasound helps to answer simple clinical questions. The corresponding answers provide essential elements for diagnostic and therapeutic decision-making. However, the emergency ultrasound also increases the safety and efficiency of interventions on the musculoskeletal system and soft tissues. In this article we will discuss common clinical emergency situations in a focused way, and we will not address the regional anesthesiological and analgesia-related applications that are also important in this context.

[CME Sonography 100: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System]. / CME-Sonografie 100: Notfallsonografie der Weichteile und des Bewegungsapparats.

CME Sonography 100: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System Abstract. The term "emergency sonography" refers to a focused sonography in emergency situations, also called emergency "Point of Care Ultrasound (POCUS)". The attending physician applies it specifically and directly to the patient. As an indispensable part of the physical examination, emergency ultrasound helps to answer simple clinical questions. The corresponding answers provide essential elements for diagnostic and therapeutic decision-making. Furthermore, the emergency ultrasound increases the safety and efficiency of interventions on the musculoskeletal system and soft tissues. In this article we will discuss common clinical emergency situations in a focused way, but we will not address the regional anesthesiologic and analgesia-related applications that are also important in this context.

[Sonographic Wall Changes of the Stone-Free Gall Bladder - a Diagnostic and Therapeutic Dilemma]. / Sonografische Wandveränderungen der steinfreien Gallenblase ­ ein diagnostisches und therapeutisches Dilemma.

Sonographic Wall Changes of the Stone-Free Gall Bladder - a Diagnostic and Therapeutic Dilemma Abstract. Various diseases frequently cause sonographic abnormalities of the gallbladder wall and its surroundings. The interpretation of these abnormalities is often a great challenge for the treating physician and will be briefly discussed here. In our patient these abnormalities are due to hepatitis A, which is responsible for multiple extrahepatic manifestations. Considering this etiology, gallbladder resection should be avoided in order to minimize unnecessary complications.

Point of care ultrasound for rapid assessment and treatment of palliative care patients in acute medical settings.

The combination of an ageing population with improving survival in malignant and non-malignant disease processes results in a growing cohort of patients with advanced or end-stage chronic diseases who require acute medical care. Emergency care has historically been stereotyped as the identification and treatment of acute life-threatening problems. Although palliative care may be considered to be new to the formal curriculum of emergency medicine, in many domains the ultrasound skillset of a physician in acute medical care can be efficaciously deployed the benefit of patients with both malignant and non-malignant disease processes that require palliative care in the full breadth of acute healthcare settings. In diagnostic domains (abdominal pain, urinary tract obstruction, dyspnoea, venous thromboembolism and musculoskeletal pain) and for specific intervention guidance (thoracentesis, paracentesis, venous access, regional anaesthesia and musculoskeletal interventions) we suggest that POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications in this important patient population. POCUS is a mandatory competence in the European curriculum of internal medicine, and specific training programs which cover applications in the domains of palliative care in acute care settings are available. Supervision, quality assurance and appropriate documentation are required. We expect that as the availability of mobile units suitable for point of care applications increases, these applications should become standard of care in the acute management of patients who require palliative care.

[COVID-19 - More Lung Pocus and Sparing Use of Stethoscope, Chest X-Ray and Lung CT]. / COVID-19 ­ mehr Lungen-PoCUS und sparsam mit Stethoskop, Thoraxröntgen und Lungen-CT umgehen.

COVID-19 - More Lung Pocus and Sparing Use of Stethoscope, Chest X-Ray and Lung CT Abstract. For an optimal management of COVID-19 (Coronary Virus Disease) we depend on a fast and reliable diagnosis and severity assessment. The gold standard so far is RT-PCR (reverse transcriptase polmerase chain reaction) from the nasopharyngeal smear. Current tests have a sensitivity of 60-90 %. As a consequence, we must expect 10-40 % false negative results. In addition to oxygen saturation for severity classification, stethoscope, chest X-ray and lung computer tomography are routinely used. However, the standard methods stethoscope and chest X-ray are unreliable. Moreover, all three diagnostic examination techniques expose physicians, support staff and subsequent patients to an additional risk of exposure. In view of the contagiousness of SARS-CoV-2 (Severe Acute Respiratory Syndrome Corona Virus), lung point-of-care ultrasound (Lu-PoCUS) is a still underutilized valuable alternative, especially when using pocket devices. In this review the current value and role of stethoscope, pulsoxymetry, chest x ray, lung computer tomography and lung point-of-care ultrasound will be determined based on the available literature.

Elevated HbA1c is not associated with recurrent venous thromboembolism in the elderly, but with all-cause mortality- the SWEETCO 65+ study.

The association of glycated hemoglobin (HbA1c) with venous thromboembolism (VTE) and death in the elderly is unknown. In the SWEETCO 65+ study we analyzed prospectively a Swiss Cohort of Elderly Patients with Venous Thromboembolism (SWITCO 65+). 888 patients were enrolled for the SWEETCO 65+ analysis. HbA1c was determined at baseline and divided into three categories (HbA1c < 5.7%, normal range; 5.7-6.49%, pre-diabetic range; and >6.5%, diabetic range). Median follow-up was 2.5 years. The primary endpoint was recurrent VTE. Secondary endpoints included all-cause mortality and major bleeds. The total prevalence of diabetes was 22.1%. The risk of recurrent VTE was similar in patients with HbA1c with pre-diabetes (adjusted subhazard ratio (aSHR) 1.07 [0.70 to 1.63]) and diabetes (aSHR 0.73 [0.39 to 1.37]) as compared to those with a HbA1c in the normal range. However, a HbA1c ≥ 6.5% (median IQ range 7.0 [6.70;7.60]) was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio [aHR] 1.83 [1.21 to 2.75]). In summary we found no association between HbA1c and major bleeding. Elevated HbA1c levels are not associated with recurrent VTE but with increased all-cause mortality in an elderly population with acute VTE.

New Perspectives for Modern Trauma Management - Lessons Learned from 25 Years FAST and 15 Years E-FAST.

E-FAST (Extended-Focused Assessment with Sonography for Trauma) is now a widely utilized and internationally recognized standard exam in trauma care. It is highly accepted by emergency physicians and trauma surgeons alike. Thanks to the popularity of PoCUS (point-of-care ultrasound), it has continued to evolve over the last years and can now improve trauma diagnosis at all stages of the primary ABCDE. This review article summarizes key observations made over recent years and also highlights the extension of FAST into E-FAST in the context of PoCUS and CT developments for modern trauma management. Time has come to learn the lessons from 25 years of FAST and 15 years of E-FAST. We should redefine and position ultrasound in the primary ATLS survey (Advanced Trauma Life Support) on two levels: 1. Basic ATLS with new clinical questions, six additional abdominal image sections and one or more follow-up examinations depending on the clinical situation, and 2. Advanced ATLS with ultrasound applications for the entire trauma ABCDE.

Risk stratification of elderly patients with acute pulmonary embolism.

BACKGROUND: Combining high-sensitivity cardiac Troponin T (hs-cTnT), NT-pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) may improve risk stratification of patients with pulmonary embolism (PE) beyond the PESI risk score. METHODS: In the prospective multicentre SWITCO65+ study, we analysed 214 patients ≥ 65 years with a new submassive PE. Biomarkers and clinical information for the PESI risk score were ascertained within 1 day after diagnosis. Associations of hs-TnT, NT-proBNP, hs-CRP and the PESI risk score with the primary endpoint defined as 6-month mortality were assessed. The discriminative power of the PESI risk score and its combination with hs-cTnT, NT-proBNP and hs-CRP for 6-month mortality was compared using integrated discrimination improvement (IDI) index and net reclassification improvement (NRI). RESULTS: Compared with the lowest quartile, patients in the highest quartile had a higher risk of death during the first 6 months for hs-cTnT (adjusted HR 10.22; 95% CI 1.79-58.34; P = 0.009) and a trend for NT-proBNP (adjusted HR 4.3; 95% CI 0.9-20.41; P = 0.067) unlike hs-CRP (adjusted HR 1.97; 95% CI 0.48-8.05; P = 0.344). The PESI risk score (c-statistic 0.77 (95% CI 0.69-0.84) had the highest prognostic accuracy for 6-month mortality, outperforming hs-cTnT, NT-proBNP and hs-CRP (c-statistics of 0.72, 0.72, and 0.54), respectively. Combining all three biomarkers had no clinically relevant impact on risk stratification when added to the PESI risk score (IDI = 0.067; 95% CI 0.012-0.123; P = 0.018; NRI = 0.101 95% CI -0.099-0.302; P = 0.321). CONCLUSIONS: In elderly patients with PE, 6-month mortality can adequately be predicted by the PESI risk score alone.

A high Gas6 level in plasma predicts venous thromboembolism recurrence, major bleeding and mortality in the elderly: a prospective multicenter cohort study.

Essentials Predictive ability of pro-hemostatic Gas6 for recurrent venous thromboembolism (VTE) is unknown. We measured Gas6 levels in 864 patients with VTE over 3 years. High Gas6 (> 157%) at diagnosis is associated with VTE recurrence, major bleeding and mortality. Gas6 plasma levels measured 12 months after the index VTE are discriminatory for VTE recurrence. SUMMARY: Background Growth arrest-specific gene 6 (Gas6) is a prohemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE results in higher mortality but does not have a higher rate of recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective To prospectively investigate the performance of Gas6 in predicting VTE recurrence, major bleeding and mortality in the elderly. Methods Consecutive patients aged ≥ 65 years with acute VTE were followed for a period of 3 years. Primary outcomes were symptomatic VTE recurrence, major bleeding, and mortality. Plasma Gas6 was measured with ELISA. Results Gas6 levels were measured in 864 patients at the time of the index VTE (T1) and, in 70% of them, also 12 months later (T2). The Gas6 level at T1 was discriminatory for VTE recurrence (C-statistic, 0.56; 95% confidence interval [CI] 0.51-0.62), major bleeding (0.60, 95% CI 0.55-0.65) and mortality (0.69, 95% CI 0.65-0.73) up to 36 months. VTE recurrence up to 24 months after T2 was discriminated by the Gas6 level at T2 (0.62, 95% CI 0.54-0.71). High Gas6 levels (> 157%) and continuous Gas6 levels at T1 were associated with VTE recurrence up to 6 months and 12 months, respectively. Conclusions In elderly patients, a high Gas6 level is associated with higher risks of VTE recurrence, major bleeding, and death. These findings support further studies to assess the performance of Gas6 in adjusting the length of anticoagulation.

Derivation and validation of a novel bleeding risk score for elderly patients with venous thromboembolism on extended anticoagulation.

Existing clinical scores do not perform well in predicting bleeding in elderly patients with acute venous thromboembolism (VTE). We sought to derive an easy-to-use clinical score to help physicians identify elderly patients with VTE who are at high-risk of bleeding during extended anticoagulation (>3 months). Our derivation sample included 743 patients aged ≥65 years with VTE who were enrolled in a prospective multicenter cohort study. All patients received extended anticoagulation with vitamin K antagonists. We derived our score using competing risk regression, with the time to a first major bleeding up to 36 months of extended anticoagulation as the outcome, and 17 candidate variables as predictors. We used bootstrapping methods for internal validation. Sixty-six (9 %) patients suffered major bleeding. The clinical score is based on seven clinical factors (previous bleeding, active cancer, low physical activity, anemia, thrombocytopenia, antiplatelet drugs/NSAIDs, and poor INR control). Overall, 48 % of patients were classified as low-risk, 37 % as moderate-risk, and 15 % as high-risk of bleeding. The rate of major bleeding was 1.4 events in low-risk, 5.0 events in moderate-risk, and 12.2 events per 100 patient-years in high-risk patients. The c-statistic was 0.78 at 3 months and 0.71 at 36 months of extended anticoagulation. Model calibration was excellent (p=0.93). Internal validation showed similar results. This simple clinical score accurately identified elderly patients with VTE who are at high risk of major bleeding and who may not benefit from extended anticoagulation. Further validation of the score is important before its implementation into practice. The study is registered to https://clinicaltrials.gov as NCT00973596.

Chest compression using the foot or hand method: a prospective, randomized, controlled manikin study with school children.

OBJECTIVE: Maintaining a chest compression depth of 5 cm or more as specified by resuscitation guidelines is difficult. Historical studies have shown an advantage of the foot method (FM) over the hand method (HM) in participants weighing less than 50 kg. Because of the fact that the importance of chest compression is increasing from guideline to guideline, the FM technique had not been evaluated conclusively and worldwide resuscitation is taught to school children, we investigated whether school children achieved a higher quality of chest compression with the FM than with the HM. METHODS: A total of 105 school children, aged 12 to 15 years, were randomized to an FM or an HM resuscitation group. After a 3 min training video, 5 min of practice, and a 5 min latent time, the participants performed a 2 min sequence of chest compressions, which was recorded on a PC and evaluated later. RESULTS: The mean percentage of correct chest compression depth (primary endpoint) was low in both groups (HM 45%, FM 47%, P=0.76). This was also found for those weighing less than 50 kg and at least 50 kg in both groups (FM 23%, HM 34%, P=0.2; FM 62%, HM 56%, P=0.57). However, the HM group was better in frequency (98 vs. 86% in FM, P=0.03) and complete decompression (99 vs. 91% in FM, P≤0.001). CONCLUSION: The FM of applying chest compression did not result in a more accurately delivered compression depth compared with the HM for children and adolescents, irrespective of body weight.