MP035: Point-of-care-ultrasound to diagnose appendicitis in a Canadian emergency department

Introduction: Appendicitis is a common surgical condition that frequently requires patients to undergo diagnostic imaging. Abdominal computed tomography is the gold standard imaging technique for the diagnosis of appendicitis, but exposes patients to radiation. Ultrasound offers an alternate radiation-free imaging modality for appendicitis. However, the availability of ultrasound during off-hours is limited in many Emergency departments (EDs). Clinician performed point-of-care ultrasound (POCUS) is increasingly used by emergency physicians as a bedside tool to evaluate suspected appendicitis. The purpose of this study is to evaluate the test characteristics of emergency physician performed POCUS to diagnose appendicitis in a Canadian ED. Methods: A pragmatic, retrospective chart review was performed on all patients for whom a POCUS was performed to diagnose appendicitis at St. Joseph’s Healthcare Hamilton in Ontario from December 1, 2010 to December 4, 2015. All POCUS scans were performed by physicians with Registered Diagnostic Medical Sonographer (RDMS) credentials or resident physicians undergoing POCUS fellowship training. All scans were over-read by RDMS credentialed faculty and subject to a rigorous quality assurance (QA) process. POCUS findings and patient outcomes were reported. Results: A total of 90 patients were included in the study. 24 patients were diagnosed with appendicitis on POCUS. Ultimately, 18 were diagnosed with appendicitis through formal imaging, laparoscopy, and pathology. The sensitivity and specificity for POCUS to diagnose appendicitis was found to be 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%) respectively. Conclusion: Bedside ultrasound is a reliable imaging modality for ruling in acute appendicitis. In cases where POCUS is negative or indeterminate for appendicitis, further imaging should be obtained as clinical suspicion warrants. The use of POCUS has the potential to reduce patient exposure to ionizing radiation and decrease the costs of obtaining CT scans, while hastening the process of achieving definitive management through earlier surgical consultation.

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The Accuracy of Point-of-Care Ultrasound in Detecting Small Bowel Obstruction in Emergency Department

Emergency Medicine International ◽

10.1155/2018/3684081 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 9

Author(s):

A. Pourmand ◽

U. Dimbil ◽

A. Drake ◽

H. Shokoohi

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Imaging Modality ◽

Point Of Care ◽

High Sensitivity ◽

Point Of Care Ultrasound ◽

Emergency Physicians ◽

Short Term ◽

Intestinal Peristalsis

Radiological imaging plays an essential role in the evaluation of a patient with suspected small bowel obstruction (SBO). In a few studies, point-of-care ultrasound (POCUS) has been utilized as a primary imaging modality in patients with suspected SBO. POCUS has been shown to be an accurate tool in the diagnosis of SBO with multiple research studies noting a consistent high sensitivity with a range of 94–100% and specificity of 81–100%. Specific sonographic findings that increase the likelihood of SBO include dilatation of small bowel loops > 25 mm, altered intestinal peristalsis, increased thickness of the bowel wall, and intraperitoneal fluid accumulation. Studies also reported that emergency physicians could apply this technique with limited and short-term ultrasound training. In this article, we aim to review the sensitivity and specificity of ultrasound examinations performed by emergency physicians in patients with suspected SBO.

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Point-of-care ultrasound to diagnose appendicitis in a Canadian emergency department

CJEM ◽

10.1017/cem.2018.373 ◽

2018 ◽

Vol 20 (5) ◽

pp. 732-735 ◽

Cited By ~ 1

Author(s):

Sameer Sharif ◽

Steven Skitch ◽

Dean Vlahaki ◽

Andrew Healey

Keyword(s):

Gold Standard ◽

Point Of Care ◽

High Specificity ◽

Point Of Care Ultrasound ◽

Likelihood Ratios ◽

Test Characteristics ◽

Patient Morbidity ◽

Additional Imaging ◽

Sensitivity Specificity ◽

Diagnostic Delays

ABSTRACTObjectivesAppendicitis is a common surgical condition that frequently requires diagnostic imaging. Abdominal computed tomography (CT) is the gold standard for diagnosing appendicitis. Ultrasound offers a radiation-free modality; however, its availability outside business hours is limited in many emergency departments (EDs). The purpose of this study is to evaluate the test characteristics of emergency physician-performed point-of-care ultrasound (POCUS) to diagnose appendicitis in a Canadian ED.MethodsA health records review was performed on all ED patients who underwent POCUS to diagnose appendicitis from December 1, 2010 to December 4, 2015. The sensitivity, specificity, and likelihood ratios were calculated. The gold standard used for diagnosis was pathology, laparoscopy, CT scans, and a radiologist-performed ultrasound.ResultsNinety patients were included in the study, and 24 were diagnosed with appendicitis on POCUS. Ultimately, 18 were confirmed to have appendicitis through radiologist-performed imaging, laparoscopy, and pathology. The sensitivity and specificity of POCUS to diagnose appendicitis were 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%), respectively.ConclusionPOCUS has a high specificity for diagnosing acute appendicitis and has very similar characteristics to those of a radiologist-performed ultrasound. These findings are consistent with the current literature and have the potential to decrease patient morbidity, diagnostic delays, ED length of stay, and need for additional imaging.

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Point-of-care ultrasound in a multiplace hyperbaric chamber

Undersea and Hyperbaric Medicine ◽

10.22462/05.06.2021.2 ◽

2021 ◽

pp. 221-226

Author(s):

Kirsten Hornbeak ◽

◽

Jay Duchnick ◽

Anthony Medak ◽

Peter Lindholm ◽

...

Keyword(s):

Imaging Modality ◽

Point Of Care ◽

Electronic Devices ◽

Point Of Care Ultrasound ◽

Clinical Settings ◽

Proof Of Concept ◽

Safety Standards ◽

Patient Assessments ◽

Hyperbaric Environment ◽

Hbo2 Therapy

Historically, electronic devices have been generally prohibited during hyperbaric oxygen (HBO2) therapy due to risk of fire in a pressurized, oxygen-rich environment. Point-of-care ultrasound (POCUS), however, has emerged as a useful imaging modality in diverse clinical settings. Hyperbaric chambers treating critically ill patients would benefit from the application of POCUS at pressure to make real-time patient assessments. Thus far, POCUS during HBO2 therapy has been limited due to required equipment modifications to meet safety standards. Here we demonstrate proof of concept, safety, and successful performance of an off-the-shelf handheld POCUS system (SonoSite iViz) in a clinical hyperbaric environment without need for modification.

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Paediatric ultrasound

Point of Care Ultrasound for Emergency Medicine and Resuscitation ◽

10.1093/med/9780198777540.003.0011 ◽

2019 ◽

pp. 217-224

Author(s):

Jason Fischer ◽

Lianne McLean

Keyword(s):

Critical Care ◽

Abdominal Pain ◽

Pyloric Stenosis ◽

Imaging Modality ◽

Point Of Care ◽

Adult Patients ◽

Point Of Care Ultrasound ◽

Lung Pathology ◽

Skull Fractures ◽

Body Habitus

This chapter highlights the increasing use of point-of-care ultrasound (PoCUS) in children. The size and body habitus of infants and children are often ideal for sonographic visualization and make PoCUS an ideal imaging modality for paediatric patients. PoCUS applications that have been traditionally used for adult patients are increasingly being adopted for the care of children. Paediatric-specific applications are also being developed for problems common and unique to paediatrics. Focused abdominal scans for appendicitis, intussusception, and pyloric stenosis are now frequently used in patients presenting with abdominal pain or vomiting. PoCUS can differentiate lung pathology and is helpful in the assessment of suspected skull fractures in non-verbal infants. Ongoing integration of PoCUS into shock, trauma, and triage algorithms support its increasing role in paediatric emergency and critical care.

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The Role and Challenges of Clinical Imaging During COVID-19 Outbreak

Journal of Diagnostic Medical Sonography ◽

10.1177/87564793211056903 ◽

2021 ◽

pp. 875647932110569

Author(s):

Mustafa Alhasan ◽

Mohamed Hasaneen

Keyword(s):

Infection Control ◽

Imaging Modality ◽

Point Of Care ◽

Limiting Factors ◽

Disease Stage ◽

Radiology Department ◽

Point Of Care Ultrasound ◽

Signal Loss ◽

Clinical Utilization ◽

Precautionary Measures

Objective: The Radiology department played a crucial role in detecting and following up with the COVID-19 disease during the pandemic. The purpose of this review was to highlight and discuss the role of each imaging modality, in the radiology department, that can help in the current pandemic and to determine the challenges faced by staff and how to overcome them. Materials and Methods: A literature search was performed using different databases, including PubMed, Google scholar, and the college electronic library to access 2020 published related articles. Results: A chest computed tomogram (CT) was found to be superior to a chest radiograph, with regards to the early detection of COVID-19. Utilizing lung point of care ultrasound (POCUS) with pediatric patients, demonstrated excellent sensitivity and specificity, compared to a chest radiography. In addition, lung ultrasound (LUS) showed a high correlation with the disease severity assessed with CT. However, magnetic resonance imaging (MRI) has some limiting factors with regard to its clinical utilization, due to signal loss. The reported challenges that the radiology department faced were mainly related to infection control, staff workload, and the training of students. Conclusion: The choice of an imaging modality to provide a COVID-19 diagnosis is debatable. It depends on several factors that should be carefully considered, such as disease stage, mobility of the patient, and ease of applying infection control procedures. The pros and cons of each imaging modality were highlighted, as part of this review. To control the spread of the infection, precautionary measures such as the use of portable radiographic equipment and the use of personal protective equipment (PPE) must be implemented.

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Point of care ultrasound in disaster triage

University of Western Ontario Medical Journal ◽

10.5206/uwomj.v86i1.2165 ◽

2017 ◽

Vol 86 (1) ◽

pp. 38-39

Author(s):

Brandon Chau ◽

Gayathri Sivakumar

Keyword(s):

Imaging Modality ◽

Point Of Care ◽

Accurate Method ◽

Point Of Care Ultrasound ◽

Life Threatening ◽

Intraperitoneal Bleeding ◽

Ultrasound Technology ◽

Fast Exam ◽

Disaster Scenario ◽

The Military

Ultrasound technology has rapidly progressed over the past decades to emerge as a portable, versatile imaging modality to complement the physical exam. It has been shown to be superior to clinical exam and equivalent to computed-tomography in detecting many life-threatening conditions, and thus is used in a variety of resuscitative settings, including the front lines of the military. A variety of imaging protocols exist for ultrasound, but in resource-deplete settings such as a disaster scenario, the focused assessment with sonography for trauma (FAST) exam is a rapid and accurate method of determining acute intraperitoneal bleeding. With improving portability, as well as the ability to transmit images to a centralized command hub, it can become a key component of the first responder’s toolkit.

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P122: The evaluation of various point of care ultrasound features in Stanford type A aortic dissections

CJEM ◽

10.1017/cem.2020.328 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S109-S109

Author(s):

T. Chiang ◽

G. Puri

Keyword(s):

Emergency Department ◽

Pericardial Effusion ◽

Aortic Dissection ◽

Aortic Root ◽

Chart Review ◽

Point Of Care ◽

Retrospective Chart Review ◽

Type A ◽

Point Of Care Ultrasound ◽

D Dimer

Introduction: Type A aortic dissection(AD) is one of the most lethal diseases in medicine. Its mortality rate increases 1-2% per hour from the onset of symptoms to treatment. Timely diagnoses of ADs, therefore, are crucial to improve survival and decrease morbidity. There are various proposed clinical guidelines to help emergency physicians decide when a CTA is urgently needed with most widely quoted being the validated Aortic Dissection Detection Risk Score(ADD-RS) recommended by the American Heart Association. The addition of D-Dimer for further risk stratification has also been entertained. A recent article published in the American Journal of Emergency recommends using point of care ultrasound(POCUS) to expedite diagnosis. With the rising use of POCUS in the emergency department, it can be the missing link to timely AD diagnoses. This project aims to elucidate the prevalence of positive POCUS findings (pericardial effusion and dilated aortic root) in type A AD via a retrospective chart review. Methods: This study is a retrospective chart review of 200 patients with the diagnosis of AD treated at Southlake Regional Hospital. We included patients diagnosed with type A AD and excluded those diagnosed with type B AD. We collected data on their demographics, ADD-RS scores, investigation results, treatments, and clinical outcomes. The main focus of the chart review was on the presence of pericardial effusion or dilated aortic root on echocardiograms. Binomial statistical analysis was used to analyze the collected data. Results: We identified 126 patients with type A AD out of 200 charts reviewed. Thirteen (14% CI 8-23%, n = 93 p = 0.05) had wide mediastinum on their chest X-rays; twenty (95% CI 75-100%, n = 21 P = 0.05) had elevated D-dimer levels; and ninety-one (72% CI 64-80%, n = 126 p = 0.05) had positive ADD-RS. Only 88 out of 126 AD cases had documented echocardiograms. Sixty-eight (77% CI 67-86%, n = 88 p = 0.05) had either pericardial effusions or dilated aortic roots on their echocardiograms. Eighty-one (92% CI 84-95%, n = 88 p = 0.05) had either positive ADD-RS or positive echocardiogram findings, which is 20 (23% CI 14-33%, n = 88 P = 0.05) more cases than ADD-RS would have picked up alone. Conclusion: The absence of both pericardial effusion and dilated aortic root on echocardiogram in combination with a negative ADD-RS has a high sensitivity for ruling out type A AD. Our data support further research into the use of POCUS to expedite the diagnosis of type A AD in the emergency department.

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P013: A new efficient and accurate scanning protocol for traumatic pneumothorax

CJEM ◽

10.1017/cem.2019.204 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S67

Author(s):

A. Bignucolo ◽

C. Acton ◽

R. Ohle ◽

S. Socransky

Keyword(s):

Ct Scan ◽

Point Of Care ◽

Data Extraction ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Point Of Care Ultrasound ◽

Evidence Based ◽

Left Hemithorax ◽

Scanning Protocol ◽

Scanning Area

Introduction: According to the International Evidence-Based Recommendations for Point-of-Care Lung Ultrasound published in 2012, the sonographic technique for evaluating a patient for a pneumothorax (PTX) “consists of exploration of the least gravitationally dependent areas progressing more laterally” in the supine patient. However, there is a wide variety of scanning protocols in the literature with varying accuracy and complexity. We sought to derive an efficient and accurate scanning protocol for diagnosing pneumothorax using point of care ultrasound in trauma. Methods: We performed a retrospective chart review of a tertiary care trauma registry from Nov 2006 to Aug 2016. We included patients with a PTX diagnosed on computed tomography (CT). Patients were excluded if they did not have an identifiable PTX on the CT scan or if they underwent a tube thoracostomy prior to the CT scan. Penetrating and blunt trauma were eligible. Data were extracted with a standardized data collection tool and 20% of charts reviewed by two reviewers. Pre defined zones were used to map area of PTXs on CT. Sensitivity, specificity and 95% CI are reported for presence of PTXs in each individual or combination of lung zones as identified on CT scan. Results: Data were collection yielded 170 traumatic PTX on chest CT with an average age of 44.2 and 77.8% male. The kappa for data extraction was 0.88. 19.4% of patients had bilateral PTX leading to a total sample size of 203. The average ISS score was 20.7 and 93% of patients survived to discharge. The length of ICU stay and hospital stay was 3.7 and 11.2 days respectively. The most accurate and efficient protocol would involve scanning the inferior border of the clavicle at the para-sternal border and again at the mid-clavicular line down to the cardiac (left hemithorax) and liver lung points (right hemithorax). The sensitivity of this scanning area in the detection of PTXs was 91.6% (95% CI 86.9-95%,). Limiting the area to the most anterior point of the chest wall increased the risk of missing a PTX (Sensitivity 89.7% (95%CI 84.6-93.5)). Conclusion: We have derived an evidence-based standardized accurate and efficient scanning protocol to rule out a pneumothorax on point of care ultrasound.

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P047: Test characteristics of point of care ultrasound for the diagnosis of retinal detachment in the emergency department

CJEM ◽

10.1017/cem.2017.249 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S93-S94

Author(s):

G. Docherty ◽

M. Francispragasam ◽

B. Silver ◽

R. Prager ◽

D. Maberley ◽

...

Keyword(s):

Emergency Department ◽

Retinal Detachment ◽

Likelihood Ratio ◽

Sensitivity And Specificity ◽

Point Of Care ◽

Small Sample ◽

Heterogeneous Group ◽

Point Of Care Ultrasound ◽

Convenience Sample ◽

Test Characteristics

Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.

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Identification of Hollow Viscus Injury with FAST Examination in Kurdistan, Iraq

Case Reports in Emergency Medicine ◽

10.1155/2018/5019415 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

Ruj Al-Sindy ◽

Heleen Alaqrawy ◽

Mahmood Sh. Hafdullah ◽

Christine Butts

Keyword(s):

Imaging Modality ◽

Point Of Care ◽

Organ Injury ◽

Free Fluid ◽

Point Of Care Ultrasound ◽

Solid Organ ◽

Hollow Viscus ◽

Northern Iraq ◽

Hollow Viscus Injury ◽

Fast Exam

Point-of-care ultrasound has become indispensable in the evaluation of trauma, particularly in low resource areas, where it may be the only rapidly available imaging modality. The FAST (Focused Assessment with Sonography in Trauma) in particular can be lifesaving, by rapidly detecting signs of intra-abdominal hemorrhage. However, the FAST is primarily designed to identify free fluid associated with solid organ injury and is thought to have less sensitivity and power in identifying evidence of hollow viscus injury. We present a case of an unidentified man that presented to a hospital in the Kurdistan region of northern Iraq, a region of low resources, surrounded by war. The FAST exam proved to be the key to identifying this patient’s injuries.

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