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

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 Accurately Distinguishes Inflammatory from Noninflammatory Disease in Patients Presenting with Abdominal Pain and Diarrhea

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2016/4023065 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 8

Author(s):

Kerri L. Novak ◽

Deepti Jacob ◽

Gilaad G. Kaplan ◽

Emma Boyce ◽

Subrata Ghosh ◽

...

Keyword(s):

Abdominal Pain ◽

Predictive Value ◽

Point Of Care ◽

Point Of Care Ultrasound ◽

Likelihood Ratios ◽

Convenience Sample ◽

Single Center Study ◽

Transmural Inflammation ◽

Inflammatory Bowel ◽

Sensitivity Specificity

Background. Approaches to distinguish inflammatory bowel disease (IBD) from noninflammatory disease that are noninvasive, accurate, and readily available are desirable. Such approaches may decrease time to diagnosis and better utilize limited endoscopic resources. The aim of this study was to evaluate the diagnostic accuracy for gastroenterologist performed point of care ultrasound (POCUS) in the detection of luminal inflammation relative to gold standard ileocolonoscopy.Methods. A prospective, single-center study was conducted on convenience sample of patients presenting with symptoms of diarrhea and/or abdominal pain. Patients were offered POCUS prior to having ileocolonoscopy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI), as well as likelihood ratios, were calculated.Results. Fifty-eight patients were included in this study. The overall sensitivity, specificity, PPV, and NPV were 80%, 97.8%, 88.9%, and 95.7%, respectively, with positive and negative likelihood ratios (LR) of 36.8 and 0.20.Conclusion. POCUS can accurately be performed at the bedside to detect transmural inflammation of the intestine. This noninvasive approach may serve to expedite diagnosis, improve allocation of endoscopic resources, and facilitate initiation of appropriate medical therapy.

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

CJEM ◽

10.1017/cem.2016.176 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S78-S78

Author(s):

S. Sharif ◽

S. Skitch ◽

D. Vlahaki ◽

A. Healey

Keyword(s):

Imaging Modality ◽

Point Of Care ◽

Retrospective Chart Review ◽

Fellowship Training ◽

Point Of Care Ultrasound ◽

Suspected Appendicitis ◽

Test Characteristics ◽

Resident Physicians ◽

Definitive Management ◽

Surgical Condition

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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Neutrophil CD64 Index as a superior biomarker for early diagnosis of infection in febrile patients in the hematology department

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2016-0118 ◽

2017 ◽

Vol 55 (1) ◽

pp. 82-90 ◽

Cited By ~ 9

Author(s):

Shu-Dao Xiong ◽

Lian-Fang Pu ◽

Hui-Ping Wang ◽

Lin-Hui Hu ◽

Yang-Yang Ding ◽

...

Keyword(s):

High Specificity ◽

Likelihood Ratios ◽

Predictive Values ◽

Combined Analysis ◽

Reactive Protein ◽

Neutrophil Cd64 ◽

Special Value ◽

Diagnostic Values ◽

Neutropenic Patients ◽

Sensitivity Specificity

Abstract Background: In the hematology department, the availability of biomarkers for early detection of infection is difficult to obtain. The present study aimed to compare the diagnostic values of neutrophil CD64 Index, procalcitonin (PCT), interleukin-6 (IL-6) and C-reactive protein (CRP) and to determine whether the combined analysis of these biomarkers offer stronger predictive power in the diagnosis for the infection of febrile patients. Methods: Neutrophil CD64 Index, PCT, IL-6 and CRP levels were determined in 356 febrile patients in the hematology ward from May 2013 to May 2015. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values, receiver operating characteristic (ROC) areas under the curve (AUC), and logistic regression analysis were determined to evaluate the diagnostic values of these biomarkers. Results: The levels of the four biomarkers were higher in the infection patients (p<0.001), and the PCT and IL-6 were higher in the patients with positive microbial blood culture (p<0.01). The neutrophil CD64 Index, PCT, IL-6, CRP had AUCs of 0.95, 0.83, 0.75 and 0.73, respectively. The best cut-off value of the neutrophil CD64 Index to detect infections was 5.06, with high specificity (87.5%) and sensitivity (88.4%). Furthermore, neutrophil CD64 Index, PCT and IL-6 offered the best combination of diagnosis with sensitivity of 93.9% and an AUC of 0.95. In addition, the neutrophil CD64 Index may have a special value to assist the physician to diagnose infection in the neutropenic patients with fever. Conclusions: The neutrophil CD64 Index is useful for early identification of infections in febrile patients in the hematology department. The combined analysis of the CD64 Index, PCT and IL-6 could further improve its sensitivity.

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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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A Simple Fask Protocol as an Effective Screening Tool for Patients With Abdominal Distention

10.21203/rs.3.rs-52530/v1 ◽

2020 ◽

Author(s):

Wan-Ching Lien ◽

Jia-Yu Chen ◽

Pei-Hsiu Wang ◽

Dean-An Ling ◽

An-Fu Lee ◽

...

Keyword(s):

Predictive Value ◽

Screening Tool ◽

Point Of Care ◽

Abdominal Distention ◽

University Hospital ◽

Admission Diagnosis ◽

Point Of Care Ultrasound ◽

Effective Screening ◽

Critical Patients ◽

Sensitivity Specificity

Abstract Background: The retrospective study aimed to investigate the effect of point-of-care ultrasound (PoCUS) by a designated protocol for patients with abdominal distention.Methods: Non-traumatic adult patients with abdominal distention were included at the emergency department (ED) of the National Taiwan University Hospital between July 2015 and July 2017. A sonographic scanning protocol (FASK, the focused assessment with sonography in trauma plus the renal US) was included in the post-graduate year and residency US training. The primary outcome included the diagnostic accuracy of the FASK protocol. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the protocol were calculated that discharge/admission diagnosis was as the standard. The secondary outcomes included ED LOS and the rate of ED discharge using the FASK protocol.Results: A total of 512 patients were included. The accuracy of the FASK protocol was 99.0% (507/512), whatever the level of the performer. The sensitivity, specificity, PPV, and NPV were 99.4% (95% CIs, 98.2-99.9%), 100% (95% CIs, 100%), 99.6% (95% CIs, 98.6-100%), and 99% (95% CIs, 97.7-99.7%), respectively. 397 patients (78%) were discharged with the median LOS of 126 minutes (IQR, 84-236 minutes) after receiving PoCUS and proper management. PoCUS was performed approximately 3 hours earlier than CT (median, 179 minutes; IQR, 90-468 minutes; p<0.0001).Conclusions: A simple FASK protocol could be an effective screening tool for non-critical patients with abdominal distention. Being an adjunct of physical examination and management, PoCUS exhibited characteristics of efficacy, timeliness, and safety.Trial registration: NCT04149041 at ClinicalTrials.gov.

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187 EFFICIENCY OF DIAGNOSIS OF CLINICAL AND SUBCLINICAL ENDOMETRITIS IN CATTLE EVALUATED BY HYSTEROSCOPY

Reproduction Fertility and Development ◽

10.1071/rdv22n1ab187 ◽

2010 ◽

Vol 22 (1) ◽

pp. 252

Author(s):

L. V. Madoz ◽

R. L de la Sota ◽

K. Susuki ◽

W. Heuwieser ◽

M. Drillich

Keyword(s):

Gold Standard ◽

Dairy Farm ◽

High Specificity ◽

University Of Edinburgh ◽

Low Sensitivity ◽

Sensitivity Specificity ◽

Rectal Palpation ◽

Subclinical Endometritis ◽

Endometrial Cytology ◽

Higher Sensitivity

The objective of this study was to evaluate the efficiency of vaginoscopy and rectal palpation (palpable liquid in uterine horns) compared with hysteroscopy (presence of pus in the uterine lumen) for the diagnosis of clinical endometritis (CE), and hysteroscopy compared with endometrial cytology for the diagnosis of subclinical endometritis (SE) in postpartum dairy cows. Thirty Holstein cows between 20 and 35 days postpartum were examined for diagnosis of CE with a vaginal speculum, by rectal palpation, and by hysteroscopy; and examined for diagnosis of SE with hysteroscopy and endometrial cytology. Categorical data were analyzed with PROC CATMOD (SAS®, SAS Institute, Cary, NC, USA) and continuous data were analyzed with PROC GLM (SAS®, SAS Institute, Cary, NC, USA). Sensitivity, specificity, predicted value of a positive and negative result, and efficiency were calculated using Win Episcope® 2.0 software (Clive, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK). Prevalence of CE diagnosed by vaginoscopy was 27%, by rectal palpation was 23%, and by hysteroscopy was 13%. When hysteroscopy, the only tool for direct examination of the endometrium, was used as the gold standard for diagnosis of CE, vaginoscopy had 100% sensitivity, 85% specificity, and 87% efficiency, and rectal palpation had 75% sensitivity, 85% specificity, and 83% efficiency. Prevalence of SE diagnosed by endometrial cytology was 35.3%. When endometrial cytology was used as the gold standard for diagnosis of SE, hysteroscopy had 11% sensitivity, 92% specificity, and 59% efficiency. In conclusion, vaginoscopy had higher sensitivity than, and similar specificity and efficiency to, rectal palpation for diagnosis of CE. Conversely, hysteroscopy, although having high specificity, had low sensitivity and efficiency for diagnosis of SE. Hysteroscopy proved to be efficient for diagnosis of CE but inefficient for diagnosis of SE. The authors gratefully acknowledge the support of the study by World of Medicine (WOM), Berlin, Germany, for providing all endoscopic equipment and the cooperation with the dairy farm in Brandenburg, Germany. Vanina Madoz visit to the Freie Universität Berlin was supported by a fellowship from the Deutscher Akademischer Austauschdienst, DAAD.

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Comparing immunochromatography with latex antigen agglutination testing for the diagnosis of cryptococcosis in cats, dogs and koalas

Medical Mycology ◽

10.1093/mmy/myz010 ◽

2019 ◽

Vol 58 (1) ◽

pp. 39-46 ◽

Cited By ~ 4

Author(s):

Mark B Krockenberger ◽

Caroline Marschner ◽

Patricia Martin ◽

George Reppas ◽

Catriona Halliday ◽

...

Keyword(s):

Gold Standard ◽

Screening Test ◽

Large Scale ◽

Point Of Care ◽

High Specificity ◽

Agglutination Test ◽

Test Results ◽

Predictive Values ◽

Cryptococcal Antigen ◽

Rule Out

AbstractAlthough the point-of-care cryptococcal antigen lateral flow assay (LFA) has revolutionized the diagnosis of cryptococcosis in human patients, to date there has been no large-scale examination of this test in animals. We therefore assessed the LFA in cats, dogs and koalas suspected of having cryptococcosis. In sum, 528 serum specimens (129 from cats, 108 from dogs, 291 from koalas) were tested using the LFA and one of two commercially available latex cryptococcal antigen agglutination test (LCAT) kits. The LCAT is a proven and well-accepted method in veterinary patients and therefore taken as the “gold standard” against which the LFA was compared. The LFA achieved a sensitivity of 92%, 100%, and 98% in cats, dogs, and koalas, respectively, with corresponding negative predictive values of 94%, 100%, and 98%. The specificity of the LFA was 81%, 84%, and 62% for cats, dogs, and koalas, respectively, with corresponding positive predictive values of 76%, 48%, and 69%. These findings suggest the most appropriate role for the LFA is as a screening test to rule out a diagnosis of cryptococcosis in cats, dogs, and koalas. Point-of-care accessibility makes it equally suited for use in the field and as a cage-side test in veterinary hospitals. The suboptimal specificity of the LFA makes it less suited to definitive confirmation of cryptococcosis in animals; therefore, all LFA-positive test results should be confirmed by LCAT testing. The discrepancy between these observations and the high specificity of the LFA in humans may reflect differences in the host-pathogen interactions amongst the species.

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Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound

Prehospital and Disaster Medicine ◽

10.1017/s1049023x18000651 ◽

2018 ◽

Vol 33 (4) ◽

pp. 406-410 ◽

Cited By ~ 3

Author(s):

Penelope C. Lema ◽

Michael O’Brien ◽

Juliana Wilson ◽

Erika St. James ◽

Heather Lindstrom ◽

...

Keyword(s):

Prospective Observational Study ◽

Point Of Care ◽

Rapid Identification ◽

Descriptive Statistics ◽

Point Of Care Ultrasound ◽

Esophageal Intubation ◽

Publication Type ◽

Employment History ◽

Patient Morbidity ◽

Study Session

AbstractObjectivesRapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation.MethodsA prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience.ResultsDuring 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location.Conclusion:Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed.LemaPC, O’BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB.Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med.2018;33(4):406–410

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Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis

CJEM ◽

10.1017/cem.2016.397 ◽

2016 ◽

Vol 19 (2) ◽

pp. 131-142 ◽

Cited By ~ 16

Author(s):

Lucas B. Chartier ◽

Laura Bosco ◽

Lauren Lapointe-Shaw ◽

Jordan Chenkin

Keyword(s):

Diagnostic Accuracy ◽

Bone Fractures ◽

Point Of Care ◽

Positive Likelihood Ratio ◽

Ankle Fractures ◽

Long Bone ◽

Point Of Care Ultrasound ◽

Fracture Rate ◽

Test Characteristics ◽

Long Bone Fractures

AbstractObjectivesLong bone fractures (LBFs) are among the most frequent traumatic injuries seen in emergency departments. Reduction and immobilization is the most common form of treatment for displaced fractures. Point-of-care ultrasound (PoCUS) is a promising technique for diagnosing LBFs and assessing the success of reduction attempts. This article offers a comprehensive review of the use of PoCUS for the diagnosis and reduction of LBFs.Data sourceMEDLINE and EMBASE databases were searched through July 19, 2015.Study selectionWe included prospective studies that assessed test characteristics of PoCUS in 1) the diagnosis or 2) the reduction of LBFs. The methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.Data extractionThirty studies met inclusion criteria (n=3,506; overall fracture rate 48.0%). Test characteristics of PoCUS for the diagnosis of LBFs were as follows: sensitivity 64.7%–100%, specificity 79.2%–100%, positive likelihood ratio (LR) 3.11–infinity, and negative LR zero–0.45. Sensitivity and specificity for the adequate reduction of LBFs with PoCUS were 94%–100% and 56%–100%, respectively. PoCUS diagnosis of pediatric forearm fractures in 10 studies showed a pooled sensitivity of 93.1% (95% confidence interval [CI], 87.2%–96.4%) and specificity of 92.9% (95% CI, 86.6%–96.4%), and PoCUS diagnosis of adult ankle fractures in four studies showed a pooled sensitivity of 89.5% (95% CI, 77.0%–95.6%) and specificity of 94.2% (95% CI, 86.1%–97.7%).ConclusionPoCUS demonstrates good diagnostic accuracy in all LBFs studied, especially in pooled results of diagnosis of pediatric forearm and adult ankle fractures. PoCUS is an appropriate adjunct to plain radiographs for LBFs.

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A near miss: subclinical saddle pulmonary embolism diagnosed by handheld ultrasound

Oxford Medical Case Reports ◽

10.1093/omcr/omab011 ◽

2021 ◽

Vol 2021 (4) ◽

Author(s):

Travis M Skipina ◽

S Allan Petty ◽

Christopher T Kelly

Keyword(s):

Pulmonary Embolism ◽

Point Of Care ◽

Pulmonary Arteries ◽

High Specificity ◽

Near Miss ◽

Pulmonary Vasculature ◽

Point Of Care Ultrasound ◽

Right Ventricular Strain ◽

Threatening Condition ◽

Low Sensitivity

ABSTRACT Introduction: Pulmonary embolism (PE) is a life-threatening condition characterized by occlusive disease of the pulmonary vasculature. Point-of-care ultrasound (POCUS) of right ventricular strain patterns have high specificity and low sensitivity for diagnosis. Here, we describe a patient with a saddle PE and low pre-test probability who was diagnosed primarily by handheld POCUS. Case Report: An 80-year old female was admitted to the intensive care unit with hypotension and lactic acidosis. She also had mild leukocytosis and troponinemia. No other clinical or metabolic abnormalities were present. After transfer to the floor, handheld POCUS demonstrated D-sign and McConnell’s sign. Computed tomography angiography showed a saddle PE involving both main pulmonary arteries. The patient was immediately initiated on anticoagulation without further complications. Conclusion: Handheld POCUS is inexpensive, carries a low risk of harm and is an invaluable extension of the physical exam when interpreted in the appropriate context.

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