Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound.

OBJECTIVES: A bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. METHODS: We conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. RESULTS: A total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71-0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. CONCLUSION: A bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectives of this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48 h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24 hr, 30 days, and 1 year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89 days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review.

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

A Novel Tool for Predicting an Abnormal Echocardiogram in Patients with Pulmonary Embolism: The PEACE Score.

BACKGROUND: Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings. OBJECTIVE: We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge. METHODS: In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed. RESULTS: 530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79-0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality. CONCLUSIONS: The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital.

Handheld Lung Ultrasound to Detect COVID-19 Pneumonia in Inpatients: A Prospective Cohort Study.

Background: Chest imaging, including chest X-ray (CXR) and computed tomography (CT), can be a helpful adjunct to nucleic acid test (NAT) in the diagnosis and management of Coronavirus Disease 2019 (COVID-19). Lung point of care ultrasound (POCUS), particularly with handheld devices, is an imaging alternative that is rapid, highly portable, and more accessible in low-resource settings. A standardized POCUS scanning protocol has been proposed to assess the severity of COVID-19 pneumonia, but it has not been sufficiently validated to assess diagnostic accuracy for COVID-19 pneumonia. Purpose: To assess the diagnostic performance of a standardized lung POCUS protocol using a handheld POCUS device to detect patients with either a positive NAT or a COVID-19-typical pattern on CT scan. Methods: Adult inpatients with confirmed or suspected COVID-19 and a recent CT were recruited from April to July 2020. Twelve lung zones were scanned with a handheld POCUS machine. Images were reviewed independently by blinded experts and scored according to the proposed protocol. Patients were divided into low, intermediate, and high suspicion based on their POCUS score. Results: Of 79 subjects, 26.6% had a positive NAT and 31.6% had a typical CT pattern. The receiver operator curve for POCUS had an area under the curve (AUC) of 0.787 for positive NAT and 0.820 for a typical CT. Using a two-point cutoff system, POCUS had a sensitivity of 0.90 and 1.00 compared to NAT and typical CT pattern, respectively, at the lower cutoff; it had a specificity of 0.90 and 0.89 compared to NAT and typical CT pattern at the higher cutoff, respectively. Conclusions: The proposed lung POCUS protocol with a handheld device showed reasonable diagnostic performance to detect inpatients with a positive NAT or typical CT pattern for COVID-19. Particularly in low-resource settings, POCUS with handheld devices may serve as a helpful adjunct for persons under investigation for COVID-19 pneumonia.

Clinical Features vs CT Findings to Estimate Need for Surgery in Small Bowel Obstruction.

This comparative effectiveness research compares the ability of clinical features vs clinical features with computed tomography (CT) to estimate the need for small bowel obstruction surgery.

Point-of-Care Ultrasound Unveiling Rotator Cuff Injuries in the Emergency Department: A Case Series.

Acute shoulder pain is a common ED presentation with a wide range of pathologies that are often initially investigated with radiography. However, diagnosing rotator cuff injuries often requires further imaging for proper diagnosis and management. Bedside shoulder ultrasound is an application that allows for the evaluation of ligaments and tendons in addition to bony structures, all while utilizing direct patient feedback of focally tender areas, expediting diagnosis and therapeutic intervention. In this case series, we discuss our evaluation of patients with suspected rotator cuff pathology and the practice of using the stepwise shoulder ultrasound protocol. Four cases are presented that illustrate the use of shoulder ultrasound in diagnosing biceps tendon injury, supraspinatus tear, chronic supraspinatus tear with hemarthrosis, and subacromial-subdeltoid bursitis. This narrative highlights the valuable role of shoulder ultrasound for the expedited diagnosis and management of patients whose initial shoulder radiographs do not indicate any bony abnormalities.

Ultrasound Assessment of Postprocedural Arterial Pseudoaneurysms: Techniques, Clinical Implications, and Emergency Department Integration.

This narrative aims to evaluate the efficacy of point-of-care ultrasound (POCUS) in the early diagnosis and management of postprocedural arterial pseudoaneurysms in the emergency department (ED). We hypothesize that POCUS can be used as the first line of imaging to distinguish vascular from non-vascular causes and diagnose a pseudoaneurysm if present. A comprehensive review of cases involving postprocedural pseudoaneurysms was conducted. We focus on patients who underwent endovascular procedures, including transfemoral and transradial arterial access for cardiac interventions, or received laceration repair after blunt head trauma. We analyzed each case's clinical symptoms, POCUS findings, and subsequent management. POCUS demonstrated high efficacy in early diagnosis by detecting pseudoaneurysm sacs with characteristic bi-directional flows (yin-yang sign) and, in some cases, partial thrombosis. The early identification of potential arterial complications allowed for efficient planning of further imaging and expedited surgical consultation, leading to timely and definitive management. Our study emphasizes the significance of using POCUS as the primary imaging modality for early detection and diagnosis of postprocedural arterial pseudoaneurysms. Incorporating POCUS into the initial assessment of patients presenting with pain and swelling at the site of arterial access or laceration repair can streamline consultation and potentially reduce the need for additional imaging, optimizing patient care in the ED setting.

Temporal Artery Ultrasound for the Diagnosis of Giant Cell Arteritis in the Emergency Department.

Giant cell arteritis (GCA), known as temporal arteritis, is a serious condition requiring immediate treatment to prevent complications. GCA can be difficult to diagnose, especially in emergency department (ED) settings where ophthalmology and rheumatology services may be unavailable. Temporal artery ultrasound (TAUS) is a valuable tool for diagnosing GCA. In the ED, TAUS can be used to quickly rule out GCA and avoid unindicated steroid treatment, which can cause serious morbidity in elderly patients. This article discusses the use of TAUS for evaluating patients with suspected GCA in the ED and its potential to expedite treatment and ensure appropriate, timely follow-up for patients with this potential vision and life-threatening condition.

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.

Novel techniques in performing extraoral ultrasound in diagnosing dental abscesses.

INTRODUCTION: Dental abscesses are a common reason patients present to the emergency department (ED). Facial and dental imaging are sometimes necessary to support the clinical diagnosis. While radiographs and computed tomography scans are frequently used, point-of-care ultrasound (US) offers several advantages, including decreased radiation exposure, reduced costs, and shorter patient length of stay. This report outlines the use of US in evaluating patients with suspected dental abscesses in the ED. DISCUSSION: The typical orofacial US techniques include examining the affected area for cobblestoning or fluid collections. To improve the accuracy of diagnoses, novel techniques such as the Oral Hydroscan (OHS) and the Tongue Pointing Techniques (TPT) may be employed in specific cases. The OHS utilizes a water-filled oral cavity to enhance the spatial resolution of ultrasound images, providing improved visualization of near-field structures and preventing air accumulation between the gingiva and the buccal mucosa. The TPT involves asking the patient to extend their tongue towards the affected area, pointing to the painful location, and serving as a visual reference for an extraoral US. CONCLUSION: US presents several advantages as an alternative imaging method for patients with suspected dental abscesses in the ED. Using innovative techniques such as the OHS and the TPT can further increase the visibility of tissue planes and help define the area of interest in these cases.

Point-of-Care Ultrasound in Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) have significant chronic health conditions that involve congenital or acquired multisystem disease associated with medical fragility, functional limitations, dependence on technology, and high health care utilization. The objective of this study was to describe the indications, applications, and point-of-care ultrasound (POCUS) findings in this population. METHODS: A descriptive study of POCUS scans performed for clinical purposes in CMC admitted to a single pediatric postacute care hospital. All children for whom a POCUS was requested by a medical team provider were eligible for inclusion. RESULTS: One hundred and four POCUS evaluations were performed for 33 patients. Diagnostic groups for the 33 patients included multiple congenital anomalies (41%), neurologic or neuromuscular (31%), prematurity (25%) and cardiac (3%). Lung, cardiac, and diaphragmatic ultrasound accounted for 57% of POCUS requested. POCUS was abnormal in 82% of diaphragmatic, 73% of lung, and 11% of cardiac ultrasounds. Twenty-three percent of POCUS studies were requested to answer a specific clinical question, 56% for follow-up information, and 21% for baseline evaluation. CONCLUSIONS: Lung, diaphragmatic, and cardiac ultrasound were the most prevalent POCUS studies requested in a postacute care hospital. POCUS may offer an expanded role in such patients and settings by answering clinical questions and by providing baseline and follow-up information.

Delayed Diagnosis of Shoulder Septic Arthritis and Osteomyelitis During the COVID-19 Pandemic: The Role of Point-of-Care Ultrasound.

The diagnosis and treatment of septic arthritis are complex and require collaboration among multiple medical services, especially in the emergency department (ED). This case report highlights the difficulties in diagnosing shoulder septic arthritis, which is a rare condition in adults and can present with subtle symptoms. The patient was eventually diagnosed with septic arthritis of the left shoulder. However, the diagnosis was delayed due to the impact of the COVID-19 pandemic on obtaining an outpatient MRI and a previous shoulder injury that added confusion. Delays in diagnosis and treatment can lead to a rapid destruction of the affected joint, causing significant morbidity and mortality. This case report also highlights the importance of alternative diagnostic tools, such as point-of-care ultrasound (POCUS), which is quick, inexpensive, and may lead to earlier detection of joint effusions and prompt arthrocentesis.

Association of Sonographic Sarcopenia and Falls in Older Adults Presenting to the Emergency Department.

BACKGROUND AND OBJECTIVE: To determine the association between point-of-care-ultrasonography (POCUS)-measured sarcopenia and grip strength, as well as the history of prior-year falls among older adults admitted to the emergency department observation unit (EDOU). MATERIALS AND METHODS: This cross-sectional observational study was conducted over 8 months at a large urban teaching hospital. A consecutive sample of patients who were 65 years or older and admitted to the EDOU were enrolled in the study. Using standardized techniques, trained research assistants and co-investigators measured patients' biceps brachii and thigh quadriceps muscles via a linear transducer. Grip strength was measured using a Jamar Hydraulic Hand Dynamometer. Participants were surveyed regarding their history of falls in the prior year. Logistic regression analyses assessed the relationship of sarcopenia and grip strength to a history of falls (the primary outcome). RESULTS: Among 199 participants (55% female), 46% reported falling in the prior year. The median biceps thickness was 2.22 cm with an Interquartile range [IQR] of 1.87-2.74, and the median thigh muscle thickness was 2.91 cm with an IQR of 2.40-3.49. A univariate logistic regression analysis demonstrated a correlation between higher thigh muscle thickness, normal grip strength, and history of prior-year falling, with an odds ratio [OR] of 0.67 (95% conference interval [95%CI] 0.47-0.95) and an OR of 0.51 (95%CI 0.29-0.91), respectively. In multivariate logistic regression, only higher thigh muscle thickness was correlated with a history of prior-year falls, with an OR of 0.59 (95% CI 0.38-0.91). CONCLUSIONS: POCUS-measured thigh muscle thickness has the potential to identify patients who have fallen and thus are at high risk for future falls.

Accuracy of "TICS" ultrasound protocol in detecting simple and complicated diverticulitis: A prospective cohort study.

BACKGROUND: Point-of-care ultrasound (US) has been suggested as the primary imaging in evaluating patients with suspected diverticulitis. Discrimination between simple and complicated diverticulitis may help to expedite emergent surgical consults and determine the risk of complications. This study aimed to: (1) determine the accuracy of an US protocol (TICS) for diagnosing diverticulitis in the emergency department (ED) setting and (2) assess the ability of TICS to distinguish between simple and complicated diverticulitis. METHODS: Patients with clinically suspected diverticulitis who underwent a diagnostic computed tomography (CT) scan were identified prospectively in the ED. Emergency US faculty and fellows blinded to the CT results performed and interpreted US scans. The presence of simple or complicated diverticulitis was recorded after each US evaluation. The diagnostic ability of the US was compared to CT as the criterion standard. Modified Hinchey classification was used to distinguish between simple and complicated diverticulitis. RESULTS: A total of 149 patients (55% female, mean ± SD age 58 ± 16 years) were enrolled and included in the final analyses. Diverticulitis was the final diagnosis in 75 of 149 patients (50.3%), of whom 53 had simple diverticulitis and 22 had perforated diverticulitis (29.4%). TICS protocol's test characteristics for simple diverticulitis include a sensitivity of 95% (95% confidence interval [CI] 87%-99%), specificity of 76% (95% CI 65%-86%), positive predictive value of 80% (95% CI 71%-88%), and negative predictive value of 93% (95% CI 84%-98%). TICS protocol correctly identified 12 of 22 patients with complicated diverticulitis (sensitivity 55% [95% CI 32%-76%]) and specificity was 96% (95% CI 91%-99%). Eight of 10 missed diagnoses of complicated diverticulitis were identified as simple diverticulitis, and two were recorded as negative. CONCLUSIONS: In ED patients with suspected diverticulitis, US demonstrated high accuracy in ruling out or diagnosing diverticulitis, but its reliability in differentiating complicated from simple diverticulitis is unsatisfactory.

Point-of Care Ultrasound in Stratifying Clinically Evolving Inguinal and Femoral Hernias.

BACKGROUND: Point-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management. OBJECTIVES: The objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias. DISCUSSION: POCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site. CONCLUSIONS: In the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias.

Optimizing Lung Ultrasound: The Effect of Depth, Gain and Focal Position on Sonographic B-Lines.

Ultrasonographic B-lines are artifacts present in alveolar-interstitial syndromes. We prospectively investigated optimal depth, gain, focal position and transducer type for B-line visualization and image quality. B-Lines were assessed at a single rib interspace with curvilinear and linear transducers. Video clips were acquired by changing parameters: depth (6, 12, 18 and 24 cm for curvilinear transducer, 4 and 8 cm for linear transducer), gain (10%, 50% and 90%) and focal position (at the pleural line or half the scanning depth). Clips were scored for B-lines and image quality. Five hundred sixteen clips were obtained and analyzed. The curvilinear transducer improved B-line visualization (63% vs. 37%, p < 0.0001), with higher image quality (3.52 ± 0.71 vs. 3.31 ± 0.86, p = 0.0047) compared with the linear transducer. B-Lines were better visualized at higher gains (curvilinear: gain of 50% vs. 10%, odds ratio = 7.04, 95% confidence interval: 4.03-12.3; gain of 90% vs. 10%, odds ratio = 9.48, 95% confidence interval: 5.28-17.0) and with the focal point at the pleural line (odds ratio = 1.64, 95% confidence interval: 1.02-2.63). Image quality was highest at 50% gain (p = 0.02) but decreased at 90% gain (p < 0.0001) and with the focal point at the pleural line (p < 0.0001). Image quality was highest at depths of 12-18 cm. B-Lines are best visualized using a curvilinear transducer with at least 50% gain and focal position at the pleural line. Gain less than 90% and image depth between 12 and 18 cm improve image quality.

Point-of-care ultrasound-first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure.

OBJECTIVES: Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point-of-care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS-first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). METHODS: We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS-first approach for SBO. The model assumes that all patients who require surgery or have non-diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. RESULTS: A POCUS-first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. CONCLUSIONS: If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.