Assessing Point-of-care Ultrasound Knowledge and Utilization among Emergency Physicians in Saudi Arabia: A Cross-sectional Survey.

Background: This study aims to assess the knowledge, perceptions, and utilization of point-of-care ultrasound (POCUS) among emergency physicians (EPs) in Saudi Arabia. Point-of-care ultrasound has emerged as a valuable tool in emergency medicine, providing real-time diagnostic information at the bedside. Understanding the current state of POCUS integration and the factors influencing its adoption is crucial for optimizing patient care in emergency settings. Materials and methods: A cross-sectional study was conducted across various hospitals in Saudi Arabia over six months. The study included 100 EPs, encompassing residents and specialists. Data were collected through an online self-administered questionnaire, exploring demographic factors, POCUS training, equipment availability, and physicians' perceptions. Statistical analyses were performed using SPSS version 28.0, including descriptive statistics and Chi-square tests. Results: The study revealed diverse demographic factors, with a majority of physicians working in regional emergency medical centers. While 84.0% of respondents had used an ultrasound device, varying levels of knowledge about POCUS were observed. Regional disparities and differences in training exposure were evident. The majority expressed positive perceptions of POCUS utility, with 67.0% recognizing its usefulness in primary care health centers. However, 31.0% only partially agreed on its daily practice utility, highlighting potential areas for intervention. Conclusion: This study provides a comprehensive assessment of POCUS awareness, knowledge, and perceptions among EPs in Saudi Arabia. The findings underscore the need for targeted educational initiatives, resource allocation, and regional considerations to enhance POCUS integration. Addressing perceived barriers and regional variations can contribute to the widespread adoption of POCUS, ultimately optimizing patient care in emergency settings. How to cite this article: Almulhim KN, Alabdulqader RA, Alghamd MK, Alqarni AA, Althikrallah FM, Alarfaj AA. Assessing Point-of-care Ultrasound Knowledge and Utilization among Emergency Physicians in Saudi Arabia: A Cross-sectional Survey. Indian J Crit Care Med 2024;28(8):769-776.

Assessment of venous congestion with venous excess ultrasound score in the prognosis of acute heart failure in the emergency department: a prospective study.

Aims: In acute decompensated heart failure (HF), systemic venous congestion contributes to patients' symptoms and hospital admissions. The purpose of our study is to determine if venous congestion, examined using the venous excess ultrasound (VExUS) score, predicts HF-related hospitalization and mortality in patients admitted to the emergency department (ED) with acute decompensated HF. Methods and results: Fifty patients admitted for acute HF in ED underwent ultrasound (US) assessment according to the VExUS score within the first 24 and 72 h. All patients were followed up with a telephone call at 30 and 60 days after hospital discharge. On admission, 56% had a VExUS score of 3. After 72 h, 32% had no more signs of congestion at the Doppler VExUS examination (inferior vena cava < 2 cm, VExUS score of 0); a similar percentage still exhibited a VExUS score of 3 despite therapy. Eighty per cent of patients were hospitalized after admission to the ED, while six (15%) died in-hospital; all exhibited a first-assessment VExUS score of 3. No patient with a VExUS score < 3 died during the study. During short-term follow-up, 18 patients were readmitted to the ED for acute decompensated HF. Ninety-four per cent of the readmitted patients had a VExUS score of 3 at the Doppler assessment at the first ED admission. Conclusion: Severe venous congestion, defined as a VExUS score of 3 at the initial assessment of patients with acute decompensated HF, predicts inpatient mortality, HF-related death, and early readmission.

Continuing professional development for primary care physicians: a pre-post study on lung point-of-care ultrasound curriculum.

BACKGROUND: Point-of-care ultrasound is rapidly gaining traction in clinical practice, including primary care. Yet, logistical challenges and geographical isolation hinder skill acquisition. Concurrently, an evidentiary gap exists concerning such guidance's effectiveness and optimal implementation in these settings. METHODS: We developed a lung point-of-care ultrasound (POCUS) curriculum for primary care physicians in a rural, medically underserved region of the south of Israel. The course included recorded lectures, pre-course assessments, hands-on training, post-workshop lectures, and individual practice. To evaluate our course, we measured learning outcomes and physicians' proficiency in different lung POCUS domains using hands-on technique assessment and gathered feedback on the course with a multi-modal perception approach: an original written pre- and post-perception and usage questionnaire. RESULTS: Fifty primary care physicians (PCPs) showed significant improvement in hands-on skills, increasing from 6 to 76% proficiency (p < 0.001), and in identifying normal versus abnormal views, improving from 54 to 74% accuracy (p < 0.001). Ten weeks after training, primary care physicians reported greater comfort using lung ultrasound, rising from 10 to 54% (p < 0.001), and improved grasp of its potential and limits, increasing from 27.5% to 84% (p < 0.001). Weekly usage increased from none to 50%, and the number of primary care physicians not using at all decreased from 72 to 26% (p < 0.001). CONCLUSIONS: A two-day focused in-person and remote self-learning lung-POCUS training significantly improved primary care physicians' lung ultrasound skills, comfort, and implementation.

Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care.

BACKGROUND: Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices. METHODS: As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables. RESULTS: The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28-59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024). CONCLUSION: Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.

Feline friendly POCUS: how to implement it into your daily practice.

PRACTICAL RELEVANCE: Cats are great pretenders; they often hide illness until they are critical. This makes patients of this species challenging to assess and manage in the emergency setting where quick and stress-free diagnosis and treatment are necessary. Veterinary point-of-care ultrasound (POCUS) is a rapid, evidence-based, non-invasive, repeatable, cage-side ultrasonographic examination designed to answer clinically driven questions without compromising feline wellbeing. Integrating feline friendly POCUS as an extension of the physical examination to streamline diagnostic and therapeutic interventions, thereby limiting stress and improving overall patient care, is advocated by the authors of this article. EQUIPMENT: Given the multitude of ultrasound machines and probes available that are portable, meaning they can be moved around the clinic and used patient-side, it should be possible for most practitioners to integrate POCUS into daily practice. The authors' preferred equipment for feline POCUS is a microconvex probe and a portable machine with a fixed pre-set. This set-up allows the clinician to complete all POCUS (abdominal, lung and pleural space, and heart) without needing to move the patient, change probes or restrain the patient in a particular position, ultimately saving time, personnel and cost while maintaining patient comfort and safety. AIM: This review aims to serve as a valuable resource for veterinarians seeking to improve their feline patient care through the judicious utilisation of POCUS. In this article, the complex challenges posed by cats are addressed, and the different POCUS techniques, applications and clinical recommendations are discussed. EVIDENCE BASE: This review draws on the published literature, as well as the authors' own collective experience when providing recommendations.

Global survey on point-of-care ultrasound (pocus) use in child surgery.

PURPOSE: To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery. METHODS: An electronic survey was disseminated via the GICS (Global Initiative of Children's Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery. RESULTS: Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available. CONCLUSIONS: Ultrasound is critically important in children's surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance.

Competencies required by sonographers teaching ultrasound interprofessionally: a Delphi consensus study.

BACKGROUND: Clinicians from multiple professional backgrounds are increasingly using point-of-care ultrasound in clinical practice. Performing ultrasound is a complex skill, and training is required to ensure competency and patient safety. There is a lack of skilled trainers within health professions to meet this increasing educational demand. The role of sonographers in educating other health professionals in point-of-care ultrasound has not yet been well defined. Sonographers can provide ultrasound education interprofessionally, if equipped with appropriate clinical knowledge and educational skills. METHODS: A Delphi consensus study was conducted to define the knowledge, skills and attributes required of sonographers teaching point-of-care ultrasound to other health professionals in Australia and New Zealand. Health professionals with subject matter expertise in the leadership, facilitation, and delivery of ultrasound education by sonographers were invited to participate. RESULTS: There were 72 expert participants in survey round one, and 49 in round two. Participants included physicians, sonographers, and other health professionals. Consensus was reached on 31 competency items for sonographers teaching ultrasound interprofessionally, with agreement of greater than 94% reached by participants. CONCLUSIONS: This consensus study has defined the knowledge, skills and attitudes required for sonographer competence in point-of-care ultrasound education. This is an important step to developing a training pathway for sonographers engaging in this emerging area.

Recommendations for Cardiac Point-of-Care Ultrasound Nomenclature.

Point-of-care ultrasound (POCUS) involves the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician. The current state of cardiac POCUS terminology is heterogeneous and ambiguous, in part because it evolved through siloed specialty practices. In particular, the medical literature and colloquial medical conversation contain a wide variety of terms that equate to cardiac POCUS. While diverse terminology aided in the development and dissemination of cardiac POCUS throughout multiple specialties, it also contributes to confusion and raises patient safety concerns. This statement is the product of a diverse and inclusive Writing Group from multiple specialties, including medical linguistics, that employed an iterative process to contextualize and standardize a nomenclature for cardiac POCUS. We sought to establish a deliberate vocabulary that is sufficiently unrelated to any specialty, ultrasound equipment, or clinical setting to enhance consistency throughout the academic literature and patient care settings. This statement (1) reviews the evolution of cardiac POCUS-related terms; (2) outlines specific recommendations, distinguishing between intrinsic and practical differences in terminology; (3) addresses the implications of these recommendations for current practice; and (4) discusses the implications for novel technologies and future research.

Optimising POCUS programs: A summary of EMUG's recommendations for the development and maintenance of ED POCUS programs.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by Clinical Leads in Ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective, and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Recommendations for developing a comprehensive point-of-care ultrasound (POCUS) program in the emergency department: an Emergency Medicine Ultrasound Group advocacy statement.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes the risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by clinical leaders in ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Venous Excess Ultrasound for Fluid Assessment in Complex Cardiac Patients With Acute Kidney Injury.

INTRODUCTION: The introduction of point-of-care ultrasound (POCUS) into clinical practice has revolutionized bedside hemodynamic assessment in recent years. POCUS has expanded its utility to include evaluating and grading venous congestion through Doppler analysis of venous blood flow. This innovative technique, VExUS (venous excess ultrasound), comprehensively evaluates venous congestion across multiple sites, including the inferior vena cava (IVC), hepatic vein, portal vein, and intrarenal vasculature. The aim of the current study was to determine whether venous excess ultrasound can help guide fluid therapy in complex patients with acute kidney injury (AKI) in addition to the standard physical examination and imaging. METHODS: Our current study shows instructive 18 clinical adult cases (enrolled between January 2024 and May 2024) to determine whether venous excess ultrasound can help guide fluid therapy in complex cardiac patients with acute kidney injury, in addition to the standard physical examination and imaging. RESULTS: VExUS was pivotal in guiding fluid therapy in all complex patients with AKI and suspected right ventricular dysfunction. By integrating VExUS findings with clinical data and cardiac ultrasound results, clinicians were able to make patient-favouring decisions regarding fluid management, diuresis, and vasopressor therapy, addressing critical aspects of conditions such as septic shock, heart failure, and acute kidney injury. CONCLUSIONS: In our study of VExUS in sick patients with AKI, we concluded that VExUS proved to be a valuable tool for fluid assessment and management. By providing real-time visualization of venous congestion, VExUS allowed for more precise and individualized fluid management strategies. This led to improved decision-making regarding fluid administration and removal, helping to prevent both fluid overload and hypovolemia. Consequently, the use of VExUS contributed to better clinical outcomes in patients with AKI, demonstrating its potential as a critical component in the management of fluid balance in this vulnerable patient population.

Utility of Common Bile Duct Identification on Biliary Ultrasound in Emergency Department Patients.

Background: Biliary ultrasound is often utilized in the evaluation of abdominal pain in the Emergency Department (ED). Common bile duct (CBD) identification is traditionally a standard component of the biliary ultrasound examination but can be challenging to perform for the novice sonographer. Previous work has demonstrated that CBD dilatation is rare in cases of cholecystitis with normal liver function tests (LFTs). We sought to assess the frequency of CBD dilatation in the subset of ED patients undergoing hepatobiliary ultrasound who have normal LFTs and an absence of gallstones or biliary sludge on ultrasound. We also performed an assessment of changes in CBD diameter by age and cholecystectomy status. Methods: This was a retrospective chart review at a single academic ED. Patients were enrolled in the study if they underwent a radiology performed (RP) hepatobiliary ultrasound within the 2 year study period. Records were reviewed for the presence of gallstones or sludge, CBD diameter, age, clinical indication for the ultrasound, and LFTs. Descriptive analyses were performed, and interobserver agreement among data abstractors was assessed by K analysis for the presence of CBD dilatation. The Mann-Whitney test was utilized to assess statistical significance in the comparison of differences between CBD diameters amongst age groups. Results: Of 1929 RP hepatobiliary ultrasounds performed in the study period, 312 were excluded and 1617 met inclusion criteria. Amongst these, there were 506 patients who had normal LFTs and an ultrasound with no stones or sludge. Ten patients within this group had a dilated CBD > 7 mm (1.98%, 95% CI of 1.08% to 3.6%). We also noted a statistically significant increase in CBD size in the older age cohort and in those individuals with a history of cholecystectomy. Conclusion: CBD dilation in ED patients who present with normal LFTs and an absence of gallstones and biliary sludge is rare. Physicians should be reassured that the routine identification of the CBD on ultrasound in this setting is of low yield and need not be pursued.

The common bile duct is often taught as part of the biliary point-of-care ultrasound examination. However, it is more challenging to identify than the gallbladder and thus may limit adoption of POCUS by ED physicians. Our study adds to the body of work demonstrating that omitting the common bile duct from an ultrasound evaluation is likely reasonable when both the gallbladder and liver function tests are normal. Our study also adds to the literature regarding the increase in common bile duct size with age and with post-cholecystectomy status.

The Use of Point-of-Care Ultrasound in the Diagnosis and Percutaneous Aspiration of Liver Abscess in a Resource-Limited Country: A Case Report.

Diagnosis and management of liver abscesses in low- and middle-income countries (LMICs) is difficult due to limited diagnostic imaging availability. Limited data is available describing the use of point-of-care ultrasound (POCUS) in the diagnosis and percutaneous aspiration of liver abscesses in resource-limited countries. We describe a 21-year-old female who was diagnosed with a liver abscess. The diagnosis of liver abscess was made via POCUS, and the patient was successfully managed with empiric antimicrobials and repeated POCUS-assisted percutaneous needle aspiration. In resource-limited settings, adequate training of personnel and availability of POCUS may help in early diagnosis and treatment of liver abscess - thus helping to reduce its related morbidity and mortality - while also aiding in resource conservation.

A shared point of care ultrasound curriculum for graduate medical education.

BACKGROUND: Point of care ultrasound (POCUS) education has grown significantly over the past two decades. Like most curricular items, POCUS education is siloed within individual graduate medical education (GME) programs. The purpose of this study was to evaluate the effectiveness of a shared GME POCUS curriculum between five GME programs at a single institution. METHODS: Post-graduate-year-1 (PGY-1) residents from emergency medicine (EM), family medicine (FM), internal medicine (IM), combined internal medicine-pediatrics (IM-Peds) and combined emergency medicine-pediatrics (EM-Peds) residency programs were enrolled in a core POCUS curriculum. The curriculum included eleven asynchronous online learning modules and ten hands-on training sessions proctored by sonographers and faculty physicians with POCUS expertise. Data was gathered about the curriculum's effectiveness including participation, pre- and post-curricular surveys, pre- and post-knowledge assessments, and an objective skills assessment. RESULTS: Of the 85 residents enrolled, 61 (72%) participated in the curriculum. Engagement varied between programs, with attendance at hands-on sessions varying the most (EM 100%, EM-Peds 100%, FM 40%, IM 22%, Med-Peds 11%). Pre- and post-knowledge assessment scores improved for all components of the curriculum. Participants felt significantly more confident with image acquisition, anatomy recognition, interpreting images and incorporating POCUS findings into clinical practice (p < 0.001) after completing the curriculum. CONCLUSION: In this shared GME POCUS curriculum, we found significant improvement in POCUS knowledge, attitudes, and psychomotor skills. This shared approach may be a viable way for other institutions to provide POCUS education broadly to their GME programs.

Automatic tablet-based monoplane quantification of stroke volume and left ventricular ejection fraction: A comparative assessment against computer-based biplane and monoplane tools.

BACKGROUND: Point-of-care cardiovascular left ventricle ejection fraction (LVEF) quantification is established, but automatic tablet-based stroke volume (SV) quantification with handheld ultrasound (HAND) devices is unexplored. We evaluated a tablet-based monoplane LVEF and LV volume quantification tool (AutoEF) against a computer-based tool (Tomtec) for LVEF and SV quantification. METHODS: Patients underwent HAND scans, and LVEF and SV were quantified using AutoEF and computer-based software that utilized either apical four-chamber views (Auto Strain-monoplane [AS-mono]) or both apical four-chamber and apical two-chamber views (Auto Strain-biplane [AS-bi]). Correlation and Bland-Altman analysis were used to compare AutoEF with AS-mono and AS-bi. RESULTS: Out of 43 participants, eight were excluded. AutoEF showed a correlation of .83 [.69:.91] with AS-mono for LVEF and .68 [.44:.82] for SV. The correlation with AS-bi was .79 [.62:.89] for LVEF and .66 [.42:.81] for SV. The bias between AutoEF and AS-mono was 4.88% [3.15:6.61] for LVEF and 17.46 mL [12.99:21.92] for SV. The limits of agreement (LOA) were [-5.50:15.26]% for LVEF and [-8.02:42.94] mL for SV. The bias between AutoEF and AS-bi was 6.63% [5.31:7.94] for LVEF and 20.62 mL [16.18:25.05] for SV, with LOA of [-1.20:14.47]% for LVEF and [-4.71:45.94] mL for SV. CONCLUSION: LVEF quantification with AutoEF software was accurate and reliable, but SV quantification showed limitations, indicating non-interchangeability with neither AS-mono nor AS-bi. Further refinement of AutoEF is needed for reliable SV quantification at the point of care.

Point-of-care ultrasound to assess left ventricular ejection fraction in heart failure in unselected patients in primary care: a systematic review.

BACKGROUND: Heart failure (HF) is the most frequent cardiovascular pathology in primary care. Echocardiography is the gold standard for diagnosis, follow-up, and prognosis of HF. Point-of-care ultrasound (POCUS) is of growing interest in daily practice. AIM: This study aimed to systematically review the literature to evaluate left ventricular ejection fraction (LVEF) assessment of unselected patients in primary care by non-expert physicians with cardiac POCUS (cPOCUS). METHODS: We searched in Medline, Embase, and Pubmed up to January 2024 for interventional and non-interventional studies assessing LVEF with cPOCUS in unselected patients with suspected or diagnosed HF in hospital or outpatient settings, performed by non-expert physicians. RESULTS: Forty-two studies were included, involving 6598 patients, of whom 60.2% were outpatients. LVEF was assessed by 351 non-expert physicians after an initial ultrasound training course. The LVEF was mainly assessed by visual estimation (90.2%). The most frequent views were parasternal long/short axis, and apical 4-chamber. The median time of cPOCUS was 8 minutes. A strong agreement was found (κ = 0.72 [0.63; 0.83]) compared to experts when using different types of ultrasound devices (hand-held and standard), and agreement was excellent (κ = 0.84 [0.71; 0.89]) with the same device. Training course combined a median of 4.5 hours for theory and 25 cPOCUS for practice. CONCLUSION: The use of cPOCUS by non-expert physicians after a short training course appears to be an accurate complementary tool for LVEF assessment in daily practice. Its diffusion in primary care could optimize patient management, without replacing specialist assessment.

Heart failure (HF) is the most frequent cardiovascular pathology in primary care. Echocardiography is the gold standard for its diagnosis, follow up and prognosis, especially for assessing left ventricular ejection fraction (LVEF), one of the essential hemodynamic cardiac markers. At a time when access to specialists is difficult, what if primary health care physicians had a tool that enabled them to sort and prioritize patients with suspected or diagnosed HF? Point-of-care ultrasound (POCUS) is already used in daily medical practice to provide optimum bedside diagnostics and tailored medical cares. Thus, we conduct a systematic review up to January 2024, including 42 studies, gathering 6598 patients with suspected or diagnosed HF, with 60% of outpatients. After a brief theoretical and practical training (a median of 4.5 hours and 25 cardiac POCUS), 351 physicians without expertise in cardiac ultrasound (defined as "non-experts") evaluated LVEF in unselected patients with cardiac POCUS, then compared with the experts' assessment. A strong to excellent agreement was found between the two groups, depending on the type of ultrasound device used. The LVEF assessment using cardiac POCUS after a short training course appears to be an accurate complementary tool for non-expert physicians. Its diffusion in primary care could optimize patient management, without replacing specialist assessment.

Beyond the Splanchnic Area: Extra-splanchnic Thrombosis in Acute Pancreatitis.

Acute pancreatitis (AP) is an inflammatory condition with varied clinical presentations. Local complications include peripancreatic fluid collection, acute necrotic collection, walled-off necrosis, and pancreatic pseudocyst, but vascular complications like pseudoaneurysm and venous thrombosis are also reported. Patients often experience splanchnic venous thrombosis, which can affect the splenic vein, portal vein, and superior mesenteric vein individually or in combination. Rarely, extra-splanchnic venous thrombosis, including renal vein, superior vena cava, and inferior vena cava thrombosis, has been reported in cases of chronic pancreatitis. The formation of a venous thrombus in acute pancreatitis is multifaceted, with pancreatic inflammation and the immune response mounted by the patient playing a significant role. There is a dearth of medical literature regarding extra-splanchnic venous thrombosis and the use of therapeutic anticoagulation in the successful treatment of the above-mentioned complication. This case report highlights the rare complications that can be seen in cases of acute pancreatitis.

Use of Point-of-Care Ultrasound to Diagnose a Ruptured Splenic Hemangioma.

An 89-year-old female presented to the emergency department (ED) with hypotension and altered mental status. The patient had no external signs of trauma or hemorrhage and no abdominal tenderness on examination. The patient remained hypotensive after initial fluid resuscitation, and laboratory testing revealed a significant anemia. Point-of-care ultrasound (POCUS) was used to perform a rapid ultrasound in shock (RUSH) exam in an attempt to uncover the etiology of undifferentiated hypotension. The exam displayed free fluid in the right upper quadrant and the left upper quadrant exam demonstrated a large splenic lesion with mixed echogenicity. Subsequent computed tomography (CT) of the abdomen and pelvis with intravenous contrast suggested a ruptured hemorrhagic splenic cyst, and the patient underwent an emergent splenectomy for hemorrhage control. Operative pathologic examination revealed the cystic lesion to be a splenic hemangioma. This case report highlights the utility of the Rapid Ultrasound for Shock and Hypotension (RUSH) protocol when evaluating patients with undifferentiated nontraumatic shock, and a rare cause of spontaneous intra-abdominal hemorrhage.

Factors associated with difficult intravenous access in the paediatric emergency department: A prospective cohort study.

OBJECTIVES: Although it is the most performed invasive procedure, peripheral intravenous catheter (PIVC) insertion in children can be difficult. The primary objective of the study was to identify the factors associated with difficult intravenous access (DIVA) in the paediatric ED, including patient, proceduralist and situational factors. METHODS: This was a single-centre prospective observational cohort study conducted over 28 consecutive days. Research assistants observed PIVC insertion attempts for children under 16 years of age and recorded data for variables relating to the patient, proceduralist and event. Univariate logistic regression modelling was performed to identify factors associated with DIVA, defined as unsuccessful PIVC insertion on the first attempt. RESULTS: A total of 134 participants were recruited; 66 were male (49%) with a median age of 5.7 years. Fifty-two (39%) were classified as having DIVA. There was a total of 207 PIVC insertion attempts with two or more attempts needed for 48 children (36%). Patient factors associated with DIVA included age of 3 years or less and limited vein options. Proceduralist factors included gestalt of 50% or less chance of success, use of a larger gauge (smaller bore) PIVC and less PIVC insertion experience. Situational factors included a combative child, higher pain score and loud ambient noise. CONCLUSIONS: The present study identified multiple patient, proceduralist and situational factors that were associated with DIVA in the paediatric ED. Future studies should explore the development and implementation of a package to address DIVA in children, with the patient-centred goals of reducing pain and improving success.

Accuracy of lung ultrasound performed with handheld ultrasound device in internal medicine: an observational study.

AIMS: Lung ultrasound (LUS) is increasingly used in Internal Medicine to complement medical examination, documenting pleural and lung conditions. This study aimed to compare the accuracy of handheld ultrasound device (HHUSD) with high-end ultrasound device (HEUSD) in patients with heart failure or pneumonia, also including the assessment of costs and time-savings. METHODS: In this observational study 72 patients (aged ≥ 18) admitted to Internal Medicine Unit for heart failure or pneumonia underwent LUS plus evaluation of inferior cava vein (ICV) when indicated, using both HHUSD and HEUSD. Each evaluation, independently performed by 2 different experienced operators, included B-lines number, pleural effusion, lung consolidations, ICV ectasia and its respiratory excursions. RESULTS: Concordance between HHUSD and HEUSD findings was 79.3% ± 17.7 (mean ± SD) for B-lines, 88.6% for pleural effusion, 82.3% for consolidations and 88.7% and 84.9% for ICV ectasia and its respiratory excursions respectively. BMI didn't significantly influence concordance between the two methods. Moreover, examination time (as mean ± SD) was shorter with HHUSD (8 ± 1.5 min) compared to HEUSD (10 ± 2.5 min). CONCLUSIONS: HHUSD demonstrated high accuracy in detecting B-lines, pleural effusions, lung consolidations and ICV evaluation when compared to HEUSD. Thus, HHUSD, not only is characterized by accessibility, portability, and easy handling due to its small size, but it also offers advantages in terms of saving costs and time, ultimately contributing to faster patient assessment compared to HEUSD.