Diagnostic accuracy of point-of-care ultrasound (PoCUS) for shoulder dislocations and reductions in the emergency department: a diagnostic randomised control trial (RCT)

2021 ◽  
pp. emermed-2020-210947
Author(s):  
Mark Anthony Attard Biancardi ◽  
Robert David Jarman ◽  
Tania Cardona
Keyword(s):  
Physical Examination ◽  
Diagnostic Accuracy ◽  
Shoulder Dislocation ◽  
Null Hypothesis ◽  
Point Of Care ◽  
Proximal Humeral Fractures ◽  
Humeral Fractures ◽  
Randomised Control Trial ◽  
Point Of Care Ultrasound ◽  
X Rays

BackgroundFollowing blunt trauma, diagnosis of shoulder dislocation based on physical examination alone is difficult due to possible concurrent proximal humeral fractures. X-rays are therefore used to confirm diagnosis. Results from recent observational studies comparing diagnostic accuracy of point-of-care ultrasound (PoCUS) with X-rays for shoulder dislocation have been encouraging. The aim of this study was to determine whether PoCUS improves diagnostic accuracy when used with physical examination for the diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the ED.MethodsA prospective, single-centre, open, parallel randomised control study over a 6-month period was used to answer the research question and test the null hypothesis. Consecutive eligible adult patients attending the ED of Mater Dei Hospital in Malta were randomised to either the control (C) (physical examination only) or experimental group (E) (physical examination and a two-point PoCUS scan). The study objectives were to measure diagnostic accuracy for both examinations for detecting shoulder dislocation, any associated proximal humeral fractures and confirming reduction. X-rays were used as reference standard for both groups.Results1206 patients were enrolled in this study (C n=600, E n=606). 290 dislocations (C n=132 and E n=158), 332 proximal humeral fractures (C n=154 and E n=178) and 278 reductions (C n=130 and E n=148) were analysed. A statistically significant difference (p<0.001) was found between the two groups for diagnostic accuracy in shoulder dislocation (C=65%, likelihood ratio (LR)+=2.03 and LR−=0.35 and E=100%, LR+=∞ and LR−=0), proximal humeral fractures (C=45.7%, LR+=1.23 and LR−=0.52 and E=98.3%, LR+=103.9 and LR−=0.03) and reduction (C=68.7%, E=100%). The null hypothesis for this study was thus rejected.ConclusionsThe addition of PoCUS to a physical examination significantly improves diagnostic accuracy for dislocations, proximal humeral fractures and reduction confirmation.Trial registration numberInternational Standard Randomised Controlled Trials Number Registry (ISRCTN17048126).

scholarly journals Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

2020 ◽  
pp. emermed-2020-209689
Author(s):  
Peter J Snelling ◽  
Philip Jones ◽  
Gerben Keijzers ◽  
David Bade ◽  
David W Herd ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Nurse Practitioners ◽  
Point Of Care ◽  
Point Of Care Ultrasound ◽  
Diagnostic Study ◽  
X Rays ◽  
Distal Forearm ◽  
Forearm Fractures ◽  
X Ray ◽  
Distal Forearm Fractures

BackgroundPaediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.MethodsThis prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4–16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as ‘no’, ‘buckle’ or ‘other’ fracture for both modalities. The primary outcome was diagnostic accuracy for ‘any’ fracture (‘buckle’ and ‘other’ fractures combined). Secondary outcomes included diagnostic accuracy for ‘other’ fractures versus ‘buckle’ and ‘no’ fractures combined, and pain, imaging duration and preference for modality.ResultsOf 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. ‘Other’ fractures (mostly cortical breach fractures), when compared with ‘buckle’/ ‘no’ fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.ConclusionsNP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of ‘any’ fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

Usefulness of point-of-care ultrasound in military medical emergencies performed by young military medicine residents

2019 ◽  
pp. jramc-2018-001132
Author(s):  
Pierre Perrier ◽  
J Leyral ◽  
O Thabouillot ◽  
D Papeix ◽  
G Comat ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Clinical Examination ◽  
Point Of Care ◽  
Military Medicine ◽  
Final Diagnosis ◽  
Absolute Difference ◽  
Point Of Care Ultrasound ◽  
Medical Emergencies ◽  
The Mean ◽  
A Prospective Study

IntroductionTo evaluate the usefulness of point-of-care ultrasound (POCUS) performed by young military medicine residents after short training in the diagnosis of medical emergencies.MethodsA prospective study was performed in the emergency department of a French army teaching hospital. Two young military medicine residents received ultrasound training focused on gall bladder, kidneys and lower limb veins. After clinical examination, they assigned a ‘clinicaldiagnostic probability’ (CP) on a visual analogue scale from 0 (definitely not diagnosis) to 10 (definitive diagnosis). The same student performed ultrasound examination and assigned an ‘ultrasounddiagnostic probability’ (UP) in the same way. The absolute difference between CP and UP was calculated. This result corresponded to the Ultrasound Diagnostic Index (UDI), which was positive if UP was closer to the final diagnosis than CP (POCUS improved the diagnostic accuracy), and negative conversely (POCUS decreased the diagnostic accuracy).ResultsForty-eight patients were included and 48 ultrasound examinations were performed. The present pathologies were found in 14 patients (29%). The mean UDI value was +3 (0–5). UDI was positive in 35 exams (73%), zero in 12 exams (25%) and negative in only one exam (2%).ConclusionPOCUS performed after clinical examination increases the diagnostic accuracy of young military medicine residents.

Diagnostic accuracy of point-of-care knee ultrasound for evaluation of meniscus and collateral ligaments pathology in comparison with MRI

2021 ◽  
pp. 028418512110582
Author(s):  
Ahmed Elshimy ◽  
Ahmed M Osman ◽  
Mohamed El Sayed Awad ◽  
Mohamed M Abdel Aziz
Keyword(s):  
Diagnostic Accuracy ◽  
Predictive Value ◽  
Point Of Care ◽  
Operative Procedure ◽  
Point Of Care Ultrasound ◽  
Collateral Ligaments ◽  
Collateral Ligament ◽  
Diagnostic Modality ◽  
Cross Sectional ◽  
Portable Ultrasonography

Background Although magnetic resonance imaging (MRI) is often the “gold standard” for diagnosing knee problems, it has many limitations. Therefore, ultrasonography has been suggested as an effective rapid alternative in many knee abnormalities, especially after injuries of the meniscus and collateral ligaments. Purpose To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) in detecting injuries of the meniscus and collateral ligament compared to MRI. Material and Methods An observational cross-sectional blinded study was conducted of 60 patients with clinically suspicious meniscus and collateral ligament injuries who were planned for an arthroscopy and or operative procedure. These patients underwent both blinded POCUS and MRI of the knees before the intervention procedure and results of both imaging modalities were compared according to the operative and arthroscopic findings. Results The preoperative reliability of POCUS compared to MRI for the assessment of meniscus injuries was sensitivity (92.9% vs. 90.5%), specificity (88.9% vs. 83.3%), positive predictive value (PPV; 95.1% vs. 92.7%), negative predictive value (NPV; 84.2% vs. 79%), and overall accuracy (91.7% vs. 88.3%). However, for diagnosing collateral ligament injures, POCUS versus MRI assessed sensitivity (92.3% vs. 88.5%), specificity (100% vs. 97.1%), PPV (100% vs. 95.8%), NPV (94.4% vs. 91.7%), and overall accuracy (96.7% vs. 93.3%). Conclusion Ultrasonography is a useful screening tool for the initial diagnosis of meniscal and collateral ligament pathology compared to or even with potential advantages over MRI, especially when MRI is unavailable or contraindicated. As newly advanced portable ultrasonography becomes available, it could be considered as a point-of-injury diagnostic modality.

scholarly journals Just the Facts: Point-of-care ultrasound in the management of shoulder dislocations

CJEM ◽  
2020 ◽  
Vol 22 (3) ◽  
pp. 287-290
Author(s):  
Ryan Henneberry ◽  
Tara Dahn ◽  
Paul Atkinson
Keyword(s):  
Emergency Department ◽  
Range Of Motion ◽  
Shoulder Pain ◽  
Shoulder Dislocation ◽  
Point Of Care ◽  
Left Shoulder ◽  
Point Of Care Ultrasound ◽  
Posterior Shoulder Dislocation ◽  
Posterior Shoulder

A 59-year-old man presents with left shoulder pain after falling while playing with his dog at the park. He drove himself to the emergency department (ED). He reports 5/10 pain and has reduced range of motion of the shoulder. His shoulder looks normal on exam and is not squared off. You wonder if he might have a posterior shoulder dislocation.

scholarly journals LO22: Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S15
Author(s):  
P. Atkinson ◽  
M. Peach ◽  
S. Hunter ◽  
A. Kanji ◽  
L. Taylor ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Diagnostic Accuracy ◽  
Diagnostic Performance ◽  
Primary Outcome ◽  
Point Of Care ◽  
Statistical Tests ◽  
Controlled Study ◽  
Point Of Care Ultrasound ◽  
Randomized Controlled ◽  
Significant Difference

Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP &lt; 100 mmHg or shock index &gt; 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.

scholarly journals P041: Accuracy of medical student-performed point-of-care ultrasound in the diagnosis of distal radius fractures in adults

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S92-S92
Author(s):  
L. Farnell ◽  
A.K. Hall ◽  
C. McKaigney
Keyword(s):  
Medical Students ◽  
Diagnostic Accuracy ◽  
Distal Radius ◽  
Point Of Care ◽  
Distal Radius Fractures ◽  
Point Of Care Ultrasound ◽  
Radiographic Imaging ◽  
Radius Fractures ◽  
Wide Range ◽  
Test Probability

Introduction: Previous investigations of the diagnostic accuracy of point-of-care ultrasound (POCUS) in distal radius fractures (DRF) report a wide range of sensitivities (71%-98%) and specificities (73%-100%) when performed by medical professionals, which may reflect inconsistencies in POCUS training or sonographer experience. The purpose of this study was to determine the accuracy of POCUS performed by pre-clerkship medical students with minimal POCUS training compared to standard radiography in diagnosing DRF in adult patients with traumatic wrist injuries, in order to assess POCUS as an alternative to traditional radiographic imaging. Methods: This prospective observational study was conducted from June to September 2015. The study population consisted of adults presenting to the emergency department (ED) with distal forearm pain secondary to traumatic injury within the past seven days and for whom radiographic imaging was ordered. Patients were evaluated using POCUS performed by medical students with no prior experience who had received one hour of POCUS training taught by an emergency ultrasound fellowship-trained ED physician. A pre-test probability of fracture was stratified as low or high and documented independently by the treating physician. Students were blinded to pre-test probability and radiography results. Results: Of the 52 patients enrolled, 18 had DRF diagnosed by radiographic imaging. Compared to radiography, student-performed POCUS had 72% overall sensitivity (95% CI, 47%-90%) and 85% specificity (95% CI, 69%-95%), with 81% overall accuracy. In the high pre-test probability group (N = 20), POCUS had 80% sensitivity (95% CI, 52%-96%) and 60% specificity (95% CI, 15%-95%). In the low pre-test probability group (N = 32), POCUS had 33% sensitivity (95% CI, 1%-91%) and 90% specificity (95% CI, 73%-98%). Conclusion: POCUS performed by medical students demonstrated reasonable success in diagnosing DRF, with overall sensitivity and specificity in keeping with published data. Within the low pre-test probability group, the diagnostic accuracy of POCUS suggests that ultrasound was an unreliable alternative to radiographic imaging for DRF in this cohort. Future analysis of the factors leading to DRF missed by POCUS as being related to adequacy of POCUS training, image capture, or sonographer experience will further explore the utility of POCUS as a diagnostic alternative.

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