Ultrasound-Guided Radial Artery Puncture by Nurses in Emergency Department: A Randomized Controlled Study.

INTRODUCTION: Radial artery puncture has been performed by palpation as a standard method in many emergency departments and intensive care units. Nurses play an important role in the care of patients in various settings. Ultrasonography can be performed and interpreted not only by physicians but also by nurses. This study aimed to evaluate whether emergency nurses would be more successful in radial artery puncture procedure by using ultrasonography instead of palpation. METHODS: This single-center, prospective, randomized controlled study was conducted in the emergency department. The patients included in the study were randomized into 2 groups as ultrasonography and palpation groups. Data were recorded on the number of interventions, the duration of the procedure in seconds, total time in seconds, whether the puncture was successfully placed, whether there were complications, the types of complications (hematoma, bleeding, and infection), or whether it was necessary to switch to an alternative technique. RESULTS: A total of 72 patients, 36 patients in the ultrasonography group and 36 patients in the palpation group, participated in the study. The success rate at the first attempt was statistically significantly higher in the ultrasonography group. Although hematoma formation among the complications occurred in the entire palpation group, it was observed in 72.2% of the ultrasonography group. Puncture time and total time were statistically significantly lower in the ultrasonography group. DISCUSSION: Our study shows that emergency nurses can use bedside ultrasonography for radial artery puncture successfully.

Factors Relating to Decision Delay in the Emergency Department: Effects of Diagnostic Tests and Consultations.

Purpose: The purpose of this study is to investigate the factors increasing waiting time (WT) and length of stay (LOS) in patients, which may cause delays in decision-making in the emergency departments (ED). Patients and Methods: Patients who arrived at a training hospital in the central region of Izmir City, Turkey, during the first quarter of 2020 were retrospectively analyzed. WT and LOS were the outcome variables of the study, and gender, age, arrival type, triage level determined based on the clinical acuity, diagnosis encoded based on International Classification of Diseases-10 (ICD-10), the existence of diagnostic tests or consultation status were the identified factors. The significance of the differences in WT and LOS values based on each level of these factors was analyzed using independent sample t-tests and ANOVA. Results: While patients for which no diagnostic testing or consultation was requested had a significantly higher WT in EDs, their LOS values were substantially lower than those for which at least one diagnostic test or consultation was ordered (p≤0.001). Besides, elderly and red zone patients and those who arrived by ambulance had significantly lower WT and higher LOS values than other levels for all groups of patients for which laboratory-type or imaging-type diagnostic test or consultation was requested (p≤0.001 for each comparison). Conclusion: Besides ordering diagnostic tests or consultation in EDs, different factors may extend patients' WT and LOS values and cause significant decision-making delays. Understanding the patient characteristics associated with longer waiting times and LOS values and, thus, delayed decisions will enable practitioners to improve operations management in EDs.

Comparison of tricuspid and mitral annular plane systolic excursion in determination of acute blood loss in healthy volunteers.

Ultrasound is used more and more in determining acute blood loss. This study is to compare tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) measurement to determine volume loss pre and post blood donation in healthy volunteers. The systolic, diastolic and mean arterial blood pressures and pulses of the donors were measured in the standing and supine position by the attending physician, then, inferior vena cava (IVC), TAPSE and MAPSE measurements were made pre and post blood donation. Statistically significant differences were found in systolic blood pressure and pulse rate values that obtained in the standing position, and in the systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse values that obtained in the supine position (p < 0.05). The difference between IVC expiration (IVCexp) pre and post blood donation was 4.76 ± 2.94 mm, and the difference in IVC inspiration (IVCins) was 2.73 ± 2.91 mm. In addition, the MAPSE and TAPSE differences were 2.16 ± 1.4 mm and 2.98 ± 2.13 mm, respectively. Statistically significant differences were found between IVCins-exp, TAPSE and MAPSE values. TAPSE and MAPSE can be helpful in the early diagnosis of acute blood loss.

Effectiveness of pericapsular nerve group block with ultrasonography in patients diagnosed with hip fracture in the emergency department.

BACKGROUND: Hip fractures (HF) are among the most common fractures present in the emergency department and are very painful. Pericapsular nerve group block (PENG) is a new regional anesthesia technique developed for analgesia in total hip arthroplas-ties. We aimed to determine the effectiveness of PENG block used to reduce pain in patients with HF in the emergency department. METHODS: This single-center, randomized, and prospective study was carried out in the emergency department. The patients in-cluded in the study were selected according to the suitability of the personnel who will perform the procedure. The sealed envelope system was used for randomization. RESULTS: Statistical analysis was performed with 39 patients (18 patients in the PENG group, 21 patients in the control group). Thir-teen (33.3%) of the patients were female and 26 (66.7%) were male. The mean age was 75.3. At rest post-procedure, the mean Numeric Rating Scale (NRS) scores of the patients at the 30th min, 2nd, 6th, and 24th h were 1.78±1.83, 0.00±0.00, 0.00±0.00, and 1.28±1.41 in the PENG group. On the other hand, it was 3.38±1.86, 0.05±0.22, 2.86±2.37, and 4.95±1.47 in the control group, respectively. The mean NRS scores of the patients at 15° elevation of the leg at the 30th min, 2nd, 6th, and 24th h were 3.06±1.80, 0.06±0.24, 0.22±0.43, and 2.44±1.50 in the PENG group and it was 5.24±1.81, 1.05±0.92, 4.29±2.35, and 7.14±1.24 in the control group, respectively. CONCLUSION: PENG block can reduce pain and the need for systemic analgesics as a practical option in patients with HF.

The role of mitral annular plane systolic excursion in prediction of acute blood loss in healthy voluntary blood donors.

Aim: The aim of this study is to compare the diameter of the inferior vena cava with mitral annular plane systolic excursion measurement in order to determine the volume loss before and after blood donation in healthy volunteers. Material and methods: The study was a single-center, prospective, cross-sectional study which included 46 healthy blood donors donating in a tertiary care hospital's blood bank. The inclusion criteria for the study were: volunteers aged 18-65 years, over 50 kg in weight, who met blood donation criteria, with hemoglobin values of >13.5 g/dL for males and >12.5 g/dL for females. After obtaining written consent, the systolic, diastolic, and mean arterial blood pressure along with the pulse rate of the donors were measured in standing and lying positions by the attending physician. Next, inferior vena cava and mitral annular plane systolic excursion measurements were made both pre and post blood donation. Results: The decrease in both inferior vena cava diameter and mitral annular plane systolic excursion values measured pre and post blood donation was found to be statistically significant (p <0.05). There was no difference between the other variables pre and post blood donation. Conclusions: Our study revealed that decreased inferior vena cava and mitral annular plane systolic excursion values correlated in determining blood loss post blood donation. Mitral annular plane systolic excursion may be useful to predict blood loss in the early stages of hemorrhagic shock.

Verification of Endotracheal Tube Position by Emergency Nurses Using Ultrasound: A Repeated Measures Cadaver Study.

INTRODUCTION: Endotracheal intubation is a lifesaving procedure frequently performed in emergency departments. It is associated with some potential risks. Rapid and reliable confirmation of endotracheal tube placement during intubation is critical. Nurses play an important role in the care of patients in various settings. Ultrasound can be performed and interpreted not only by physicians but also by nurses. The aim of this study was to evaluate how well nurses without previous ultrasound experience can determine both esophageal and tracheal localization of endotracheal tubes in cadavers after a short ultrasound training. METHODS: This was a repeated measures study with an educational intervention and no control/contemporaneous comparison group. The study was performed to evaluate the ability of emergency nurses to confirm correct endotracheal tube placement and identify esophageal intubations. A total of 7 emergency nurses were given theoretical education and hands-on training about ultrasound. They diagnosed tracheal or esophageal intubation using ultrasound. RESULTS: Four cadavers were used 8 times each for the study. A total of 32 intubation procedures were evaluated with ultrasound by each nurse. In the analysis based on 224 responses, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and overall accuracy of ultrasound applied by nurses to detect tracheal intubation were 95.61% (90.06%-98.56%), 97.27% (92.24%-99.43%), 35.06 (11.48-107.10), 0.05 (0.02-0.11), and 96.43% (93.08%-98.45%), respectively. The mean time to evaluate the tube location by ultrasound was 6.57 seconds. DISCUSSION: The results support that ultrasound can be performed by nurses for the confirmation for esophageal and tracheal intubations quickly and accurately.

The role of tricuspite annular plane systolic excursion as a marker of hypovolemia in healthy blood donor volunteers.

AIM: The aim of this study is to compare the diameter of the inferior vena cava with tricuspid annular plane systolic excursion (TAPSE) measurement in order to determine the volume loss before and after blood donation in healthy volunteers. METHODS: This Institutional Review Board-approved single center, prospective, cross-sectional study included 60 healthy blood donors donating in a tertiary care hospital's blood bank. After obtaining written consent, systolic, diastolic, and mean arterial blood pressures along with pulse rate of the donors were measured in sitting and supine positions by the attending physician, then, inferior vena cava (IVC) and TAPSE measurements were made before and after blood donation. RESULTS: Statistically significant differences was found between standing systolic blood pressure and pulse rate, lying systolic blood pressure and pulse rate, IVC and TAPSE values before and after blood donation (p < 0.05). There was no difference between the other variables before and after blood donation. CONCLUSION: Our study revealed that, low IVC and TAPSE values correlated in determining blood loss after blood donation. TAPSE may be useful to predict blood loss in early stages of hypovolemic shock.

Simple Manual Pressure with Ultrasound-Guided Femoral Nerve Block: A randomized single blind study.

PURPOSE: The aim of this study was to investigate the effect of compression on the Visual Analog Scale (VAS) score following the application of 3-in-1 femoral nerve block (FNB), used for pain palliation in patients with hip fractures. METHODS: This was a randomized controlled trial study on application of pressure versus no pressure following FNB in patients with hip fractures. Their VAS scores were recorded and an ultrasound-guided 3-in-1 FNB was performed as a standardized procedure. After the procedure, patients were randomized into two groups and a weight with 2 kg pressure was applied to the treated area in one group. After 30 min, VAS scores were recorded again. VAS scores of all patients recorded before and after the procedure, and post-procedural VAS scores of pressure-applied and no pressure-applied groups were statistically compared. RESULTS: 34 patients were included in this study with 17 patients falling in the compression group (group C), and the remaining half in the non-compression group (group NC). The pre-procedural mean VAS scores were 9.35 (95% CI; 8.95-9.76)), while the post-procedural mean VAS scores dropped to 2.35 (95% CI; 1.65-3.06) in group C. The pre-procedural mean VAS score was 9.12 (95% CI; 8.64-9.59), while the post-procedural mean VAS score was 5.06 (95% CI; 4.09-6.03) in group NC. When the average reductions in VAS score following the procedure were compared, the mean difference between the two groups was calculated to be 2.94 (95% CI; 1.69-4.19) which favours group C. This difference was statistically significant (p < 0.001). CONCLUSION: Our study shows that, the application of simple compression after 3-in-1 FNB in patients with hip fractures provides a significant reduction in VAS scores.

Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST-Elevation Myocardial Infarction.

OBJECTIVES: Our aim was to evaluate the accuracy of emergency physicians (EPs) in the detection of regional wall motion abnormalities (RWMAs) using focused cardiac ultrasound (FOCUS) in patients suspected of non-having ST-elevation myocardial infarction. METHODS: We prospectively enrolled patients with chest pain. Three EPs underwent didactics and hands-on-training, of 3 hours each, by an experienced cardiologist, on detecting RWMAs using 2-dimensional echocardiography. They performed a FOCUS examination to evaluate for RWMAs and recorded the echo images. Our reference standard for the detection of RWMAs was accepted as a blinded cardiologist review of the prerecorded video clips. We calculated the corrected sample size and inter-rater agreement between the EPs (82 and 0.83, respectively). The analysis of the study was performed on 89 patients. RESULTS: Eighty-nine patients with chest pain were screened. Emergency physicians demonstrated the detection of RWMAs with good sensitivity and even excellent specificity: 76.9% (95% confidence interval [CI], 56.4%- 91.0%) and 92.1% (95% CI, 82.4%-97.4%), respectively. The accuracy of FOCUS was 87.6% (95% CI, 79.0%-93.7%). The area under the curve from a receiver operating characteristic curve analysis, which evaluated the EPs' rate of detecting the presence or absence of RWMAs, was 0.845 (95% CI, 0.753-0.913). CONCLUSIONS: Our study results suggest that EPs with training in bedside echocardiography can accurately rule in patients with RWMAs in suspected non-ST-elevation myocardial infarction cases.

Accuracy of Bedside Lung Ultrasound as a Rapid Triage Tool for Suspected Covid-19 Cases.

OBJECTIVES: The novel coronavirus disease 2019 (Covid-19) outbreak began in China. The characteristic of the disease is development of pneumonia. We aimed to investigate the accuracy of bedside lung ultrasound (BLUS) for diagnosing Covid-19 pneumonia, and its effectiveness for the correct triage of patients with suspected Covid-19 in the emergency department (ED). METHODS: This study was a prospective, cross-sectional cohort study. During their shifts, 3 accredited and certificated emergency physicians performed BLUS using BLUE protocol at the triage area of the ED on patients with suspected Covid-19. All of the patients underwent chest computed tomography. The BLUS findings were statistically compared with formal radiology reports of computed tomographies as the criterion standard for the diagnosis of Covid-19 pneumonia. Kolmogorov-Smirnov analysis, Shapiro-Wilk test, and Q-Q plots were performed with 95% confidence intervals (CIs) for statistical analysis. RESULTS: A total of 72 patients were included in the study. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of BLUS were 96.9% (95% CI, 84.2%-99.9%), 92.3% (95% CI, 79.1%-98.3%), 84.3% (95% CI, 64.5%-94.1%), 98.6% (95% CI, 91.1%-99.8%), and 93.7% (95% CI, 85.3%-98.0%), respectively. The positive and negative predictive values were 84.3% (95% CI, 64.5%-94.1%) and 98.6% (95% CI, 91.1%-99.8%), respectively. The area under curve was found to be 0.946 (95% CI, 0.866-0.986; P < 0.0001). CONCLUSIONS: Bedside lung ultrasound can be used to detect the presence of pulmonary involvement in suspected cases of Covid-19 for the effective triage of patients in the ED.

Bedside Echocardiography in Acute Myocardial Infarction Patients with Hemodynamic Deterioration.

Ventricular septal (VS) rupture after acute myocardial infarction (AMI) is an uncommon complication in the reperfusion era. Bedside echocardiography (BECH) continues to be a strong diagnostic tool for emergency physicians treating dyspneic patients, especially for decision-making on the management strategies to use with these unstable patients. In the case we present here, a patient is diagnosed with a delayed mechanical complication after AMI, and a swift management plan is made with the aid of point-of-care BECH. The patient is a 72-year-old man with dyspnea who was admitted to the ED 5 days after receiving a primary percutaneous coronary intervention with stent implantation for AMI; in the ED, the patient was diagnosed, via BECH, with a VS rupture. On arrival, his vital signs and the results of his physical examination depicted shock and low perfusion with wet lung. A cardiac examination revealed a new 2/6 harsh holosystolic murmur along the left sternal border without pretibial oedema. Emergency physicians performed BECH, and subcostal views of the heart revealed a wide interventricular septal rupture and left-to-right shunting with minimal pericardial effusion. The patient underwent surgery immediately to repair the defect. The post-operative course was uneventful, and he was discharged in stable condition on the seventh day after the surgery. The use of BECH to recognize a VS rupture is critical because such a defect may be the most important determinant of mortality in AMI patients who are in shock. BECH thus can influence clinicians' acute management and disposition decisions.

Urine Dipstick of Sputum for the Rapid Diagnosis of Community Acquired Pneumonia.

INTRODUCTION: Community acquired pneumonia (CAP) is responsible for an important part of treatment costs across the world. Even though posterior-anterior lung radiography (PALG) and direct sputum smear microscopy are required or routine diagnoses. The purpose of this study is to determine the diagnostic value of the bedside urine strip tests in CAP. METHODS: Patients who attended the emergency department (ED) between from February 2016 to September 2016 with expectoration complaints and suspicion of pneumonia. The sensitivity, specificity, and accuracy rate of the urine strip tests, direct sputum smear microscopy, and PALG were calculated and analyzed using SPSS 15.0. RESULTS: During the study period, 100 patients with pneumonia suspicion were evaluated in the ED. The sample was divided into two groups: negative and positive diagnosis of CAP. The leukocytes detecting by urine strip tests are statistical differences between the two groups (p: 0.003). The results show that the sensitivity, specificity, and accuracy rate of leukocytes detected in sputum with urine strip tests in the pneumonia diagnosis were 83.3%, 44.2% and 63% respectively. CONCLUSION: According to the study, it is believed that the method of determination of leukocytes with urine strip tests in sputum combined with more detailed results. They can become part of CAP diagnosis methods.

Effectiveness of Bedside Lung Ultrasound for Clinical Follow-Up of Primary Spontaneous Pneumothorax Patients Treated With Tube Thoracostomy.

Primary spontaneous pneumothorax (PSP) is a common cause of presentation to emergency departments and subsequent hospitalization. Patients with large PSP are treated with tube thoracostomy (TT) and followed up with x-rays. In this study, we investigated the efficiency of bedside ultrasound and compared it with x-ray imaging for the clinical follow-up of PSP patients treated with TT.This is a prospective observational study. After ethical committee approval and written informed consent were obtained, patients who were treated with TT because of PSP were screened. In the follow-up of these patients, a bedside lung ultrasound (BLUS) was performed before every chest x-ray by an emergency physician experienced in performing BLUSs. The performance of BLUSs in detecting free air in the pleural cavity was compared statistically with that of x-rays.Sixty-two patients were enrolled in the study. In total, 166 BLUSs and x-rays were compared. The sensitivity of BLUS was 95.65% (85.20-99.50), specificity was 100% (79.40-100.00), positive predictive value was 100% (92-100), negative predictive value was 88.90% (65.30-98.60), and the area under the curve was 0.99 (0.974-1.000; P = 0.001) for detecting air in the pleural cavity. These results showed that there was no statistically significant difference between BLUS and x-ray methods for detecting air in the pleural cavity.Our study revealed that BLUS can be safely used for the follow-up of PSP patients treated with TT to determine if air is present in the pleural cavity. Further studies are needed.

Different manifestation of a familiar diagnosis: From anuria to acute appendicitis.

The differential diagnosis of anuria in emergency department (ED) is broad. Secondary to intraabdominal mass pressure or infections, symptoms of micturation difficulties or disuria accompanying to back pain may arise with the interruption of sacral nerve stimulation. Here, we report a patient who admitted to ED with back pain and anuria and diagnosed acute appendicitis (AA) after advanced investigation despite of not to have any abdominal pain. A 36-year-old man admitted to our ED with a 6-h history of back pain and urination difficulty. 750mL of clear urine output was observed after bladder catheterization. Abdominal computerized tomography with intravenous contrast was used and revealed acute appendicitis. The patient consulted with a general surgeon and hospitalized for operation. After the operation, back pain was disappeared, and spontaneous micturition was seen. This case not only represents an uncommon manifestation of AA, but also alerts us to the importance of anatomical considerations when interpreting disease extent with imaging. In the differential diagnosis of back pain and urination difficulty, the rare possibility of AA should be taken into account. Because the presence of unusual findings, such as those associated with the urinary tract or lumbosacral pathologies, may further obscure the diagnosis and delay appropriate therapy.

The diagnosis of pulmonary embolism without contrastis not always Challenging: be aware of hyperdense lumen sign.

Acute pulmonary embolism (PE) diagnosis is a challenging task, despite the advanced diagnostic methods for both clinicians and radiologists. Awareness of the "hyperdense lumen sign" in patients obtained un-enhanced computarized tomography (CT) of chest mayhelp to establish an acute PE diagnosis, especially in clinically non suspected PE patients. A 78-year-old woman was brought to our emergency department (ED) with an aphasia complaint. The patient's dizziness improved in ED. Neurological examination returned to base line status but sinus tachycardia and low saturation value on room air were continuing. Un-enhanced CT of the chest demonstrates hyperdense material within the right main pulmonary artery. Contrast-enhanced CTPA demonstrated hypodense filling defect within the rigth main pulmonary artery consistent with PE. Independent of the patient's complaint, the measurement of all vital signs is important especially in elderly patients. Emergency physicians have to be aware of that the "hyperdense lumen sign" may point out PE and should be prevented from delayed recognition.

An Unexpected Reason for Isolated Foot Drop: Acute Stroke.

The differential diagnosis of acute weakness (AW) in emergency departments (ED) is broad and includes both neurological and medical reasons. We describe an 81-year-old female patient with cortical infarct presenting with sudden onset isolated foot drop, which to the best of our knowledge, was the third case in English literature. An 81-year-old female was admitted to our ED with a 12-hour history of left-sided foot drop. Her motor strength was normal throughout the upper and lower extremities, except for weakness in the left ankle and toe dorsiflexors. Other examination findings were unremarkable. Diffusion-weighted magnetic resonance imaging (DWI-MR) revealed a focal high intensity signal in the right precentral gyrus at high convexity with a cerebral infarct. Detailed physical examinations and histories are extremely important for exact diagnosis and differentials of patients with AW. This case reminds us that a small infarct area of central nervous system may mimic peripheral nerve lesions, especially in elderly patients. Although the presentation of such complaints may play a distracting role to emergency physicians, strokes must always be taught regarding elderly patients and, if necessary, infarct areas should be confirmed with DWI-MR.

An unanticipated diagnosis with bedside ultrasonography in patients with acute abdominal pain: rectus hematoma.

Although abdominal pain is a common presentation in emergency departments, rectus sheath hematoma (RSH) is among the rarest diagnosis. Here we present 2 cases of RSH likely caused by coughing due to upper respiratory tract infection. The two described cases were diagnosed by bedside ultrasonography and confirmed as RSH by computed tomography. Review of patient history and use of ultrasonography are important to avoid misdiagnosisof RSH.

A bedside ultrasound technique for fluid therapy monitoring in severe hypovolemia: Tissue Doppler imaging of the right ventricle.

Fluid therapy is one of the main issues for hemodynamic resuscitation. Tissue Doppler imaging (TDI) of the right ventricle (RV) with bedside ultrasound (BUS) technique is a new dynamic method to identify fluid responsiveness in patients with hypotension. Here, we present the case of a hypotensive patient monitored with TDI measurements of RV. A 75-year-old male patient was admitted to the emergency department (ED) with the complaint of diarrhea. He was in severe hypovolemia, with hypotension, tachycardia, and tachypnea. His laboratory results were normal. BUS was performed on the patient by the ED physician. The velocity of the excursion of the tricuspid valve measured at presentation was 14.47 cm/s and, together with collapsed inferior vena cava (IVC), this finding led to the decision to begin fluid therapy immediately. The patient underwent 2 L of fluid therapy with 0.9% NaCl in a 2-h period. Control BUS after fluid therapy revealed decreased TDI velocity of tricuspid annulus to 11.81 cm/s and dilated IVC not collapsing sufficiently with respiration. The patient received his maintenance therapy after admission to the internal medicine department and was discharged from the service after 3 days. TDI in fluid responsiveness may find a clinical role in the future by the clinical studies.

Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis.

BACKGROUND: Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis. METHODS: Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital. RESULTS: The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis. CONCLUSION: BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.