Point-of-care Ultrasound Identification of Tension Hydrothorax in the Emergency Department: A Case Series.

INTRODUCTION: Tension hydrothorax is an uncommon emergent condition in which hemodynamic instability and respiratory compromise may occur. Emergency physicians may diagnose tension hydrothorax by point-of-care ultrasound. CASE SERIES: We discuss the key sonographic features assisting in identification. Four patients with history of malignancy who were found to have tension hydrothorax exhibited the following common ultrasound findings: massive, left-sided pleural effusion; complete, compressive atelectasis; and shift of cardiac structures into the right hemithorax, resulting in right-sided probe placement to obtain cardiac views. CONCLUSION: This is the first instance to our knowledge of point-of-care ultrasound findings in tension hydrothorax to be described in the literature.

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians.

INTRODUCTION: Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED). METHODS: Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers. RESULTS: 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was "No structured curriculum to educate physicians on POCUS." The top-ranked personal barriers were "I do not feel comfortable with my POCUS skills" and "I do not have sufficient time to dedicate to learning POCUS." The top-ranked barriers for resident physicians were "Time to retrieve and operate the machine" and "Chaotic milieu." CONCLUSIONS: While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department. METHODS: Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock. RESULTS: A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock. CONCLUSION: The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.

Bilateral hydronephrosis and cystitis resulting from chronic ketamine abuse.

Ketamine associated urinary dysfunction has become increasingly more common worldwide. Point-of-care ultrasound (POCUS) is an established modality for diagnosing hydronephrosis in the emergency department. We describe a case of a young male ketamine abuser with severe urinary urgency and frequency in which POCUS performed by the emergency physician demonstrated bilateral hydronephrosis and a focally thickened irregular shaped bladder. Emergency physicians should consider using POCUS evaluate for hydronephrosis and bladder changes in ketamine abusers with lower urinary tract symptoms. The mainstay of treatment is discontinuing ketamine abuse.