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We evaluated agreement among trained emergency physicians assessing the degree of B-line presence on bedside ultrasound in patients presenting to the emergency department (ED) with acute undifferentiated dyspnea. We also determined which thoracic zones offered the highest level of interobserver reliability for sonographic B-line assessment. We evaluated a prospective convenience sample of adult patients presenting with dyspnea to an academic ED. Two consecutive bedside lung ultrasounds were performed on 91 patients by a pair of physician-sonographers. The lung ultrasounds were structured 10-zone thoracic sonograms, documented as videos. Sonographer pairs were expert/expert (>100 lung ultrasounds performed) or expert/novice pairs (novices performed 5 supervised examinations after structured training) and blinded to clinical data. Sonographers reported B-line concentration with 3 assessment methods: (1) normal (<3 B-lines) or abnormal (≥3 B-lines); (2) ordinal (normal, mild, moderate, or severe), and (3) counting B-lines (0-10; >10) in each zone. All statistical analyses were performed using SPSS version 18.0 (Chicago, IL) and Stata 12.1 (College Station, TX). We evaluated interrater and intrarater agreement using Intraclass correlation coefficients (ICCs). The right and left anterior/superior lung zones showed substantial agreement in all assessment methods and demonstrated best overall agreement (ICC for right: counting, ordinal, and normal/abnormal, 0.811 [0.714-0.875], 0.875 [0.810-0.917], and 0.729 [0.590-0.821], respectively). Furthermore, both expert/expert pairs and expert/novice pairs showed substantial agreement in the right and left anterior/superior thoracic zones (expert/expert, 0.904 and 0.777, respectively; expert/novice, 0.862, and 0.834, respectively). Second best agreement was found for the lateral/superior lung zones (right: counting, ordinal, and normal/abnormal, 0.744 [0.612-0.831], 0.686 [0.524-0.792], and 0.639 [0.453-0.761], respectively; and ICC left: counting, ordinal, and normal/abnormal, 0.671 [0.501-0.782], 0.615 [0.417-0.746], and 0.720 [0.577-0.815], respectively). When comparing agreement to distinguish “normal vs abnormal” B-line findings, our results showed significant agreement in all zones with the exception of the right and left inferior/lateral lung fields and left posterior lung. Reinterpretation by 2 experts of all their own randomized video clips at a later date showed agreement of 0.697 (n = 733 zones) and 0.647 (n = 266) zones for ordinal assessment of B-line concentration. Interrater agreement was best in the anterior/superior thoracic zones followed by the lateral/superior zones for both expert/expert and expert/novice pairs. Agreement in the lateral/inferior lung zones was overall inferior. Intrarater agreement was highest at extreme high or low numbers of B-lines.

BackgroundMany point-of-care ultrasound devices are now “pocket-sized” or handheld, allowing easy transport during travel and facilitating use in crowded spaces or in austere low-resource settings. Concerns remain about their durability, image quality, and clinical utility in those environments.MethodFive emergency physicians with training in point-of-care ultrasound employed the Butterfly iQ, a novel handheld ultrasound device, in routine clinical care in a busy, high-acuity African emergency department over a period of 10 weeks. We retrospectively evaluated the performance of the Butterfly iQ from the perspectives of both the clinicians using the device and expert ultrasound faculty reviewing the images.ResultsWe found advantages of the Butterfly iQ in a high-acuity African emergency department include its use of a single probe for multiple functions, small size, ease of transport, relatively low cost, and good image quality in most functions. Disadvantages include large probe footprint, lower, though still adequate, cardiac imaging quality, frequent overheating, and reliance on internet-based cloud storage, but these were surmountable. We also report a wide variety of patient presentations, pathology, and procedures to which the device was used.ConclusionWe conclude the Butterfly iQ is an effective, though imperfect, point-of-care ultrasound device in a low-resource emergency setting. We will continue to employ the device in clinical emergency care and teaching in this setting.

Introduction: Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. Case Report: We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point-of-care ultrasound associated with traumatic hand amputation. The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition 10 days later. Conclusion: Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Ectopic pregnancy (EP) is a life-threatening condition requiring a high clinical suspicion. This diagnosis must be considered in all female patients of reproductive age presenting with abdominal pain or discomfort who may possibly be pregnant. Ectopic pregnancies occur in a small percentage of all pregnancies and are a significant cause of maternal morbidity and mortality. Abdominal ectopic pregnancy (AEP) is a rare and potentially fatal form of ectopic pregnancy where the implantation occurs in the abdominal cavity. We present the following case of a 23-year-old female who was transferred following an initial workup for abdominal pain and subsequently found to have an abdominal ectopic pregnancy at 37 weeks gestation. After transferring to our emergency department, the patient continued to have abdominal pain and her presenting FAST exam was positive for free fluid concerning for active hemorrhage and hematoma. Her clinical presentation was consistent with ruptured abdominal ectopic pregnancy, and she was taken to the operating room for emergent exploratory laparotomy and delivery. Her clinical course was complicated by adherent placenta and re-bleeding with significant hemoperitoneum requiring re-entry laparotomy and transfusion. We present the details of this case along with the diagnostic imaging and management of the rarely seen and life-threatening condition of secondary abdominal ectopic pregnancy (AEP).

Echocardiography has contributed to the care of critically ill patients but there remains a need for more publications about its association with outcomes to confirm its role. We conducted a retrospective review of trauma and burn patients that were admitted to our intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography. Data collected included demographics, clinical and laboratory data. Right ventricle fractional area of change (RVFAC) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clips. There were 74 patients, mean age was 51 years, and were predominantly white and male. Linear regression was used to test for the association between RVFAC and clinical outcomes. Adjusting for age, injury mechanism and injury severity, higher RVFAC was significantly associated with lower ventilator days (p = 0.03). Conclusion, higher right ventricle systolic function is associated with a lower number of ventilator support days in critically injured trauma and burn patients. •A retrospective review of trauma and burn patients that were admitted to an intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography.•Right ventricle fractional area of change (RVFAC) and tricuspid area plane systolic excursion (TAPSE) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clip segments.•Higher RVFAC was significantly associated with decreased ventilator days (p = 0.03).

BackgroundThe role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula.ObjectivesWe describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS.ConclusionOur curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.

Acute kidney injury (AKI) is a serious condition that affects critically ill patients admitted to the ICU. In this study, we report the association between right ventricle shape and AKI in a cohort of burn and trauma patients. This study is a retrospective review of trauma and burn patients who were admitted to our ICU between 2013 and 2016 who underwent hemodynamic transesophageal echocardiography. Left ventricular eccentricity index (LVEI) measurements were performed on still images obtained from transgastric short-axis view clips at end diastole. LVEI was used as a surrogate of right ventricular volume loading. There were 132 patients, the mean age was 50.8 years, and they were predominantly white and males. Using logistic regression and adjusting for age, race, gender, injury mechanism, and injury severity, higher LVEI was independently significantly associated with lower incidence of AKI (odds ratio 0.03, confidence interval 0.00–0.69). Higher LVEI is associated with a lower incidence of AKI in critically injured trauma and burn patients.

Background and purpose Liver cirrhosis is common, and timely diagnosis of decompensated cirrhosis may impact acute care and resuscitation. Point-of-care ultrasound is a core competency of US emergency medicine training and is increasingly available in many acute care settings, including those where usual diagnostic modalities of cirrhosis may not be available. Only a few works of literature exist that evaluate the ultrasound diagnosis of cirrhosis and decompensated cirrhosis by emergency physicians (EPs). We aim to evaluate whether EPs can diagnose cirrhosis by ultrasound after a brief educational intervention and determine the accuracy of EP-interpreted ultrasound compared to the radiology-interpreted ultrasound as a gold standard. Methods This single-center prospective single-arm educational intervention evaluated the accuracy of EPs diagnosing cirrhosis and decompensated cirrhosis on ultrasound before and after a short educational intervention. Responses were paired across the three assessments, and paired sample t-tests were performed. Sensitivity, specificity, and likelihood ratios were calculated using attending radiology-interpreted ultrasounds as the gold standard. Results EPs scored a mean of 16% higher on a delayed knowledge assessment one month after the educational intervention than on the pre-intervention assessment. EP-interpreted ultrasound revealed a sensitivity of 0.90, specificity of 0.71, positive likelihood ratio of 3.08, and negative likelihood ratio of 0.14 compared to radiology-interpreted ultrasound. The sensitivity of our cohort was 0.98 for decompensated cirrhosis. Conclusions After a brief educational intervention, EPs can significantly increase their sensitivity and specificity in diagnosing cirrhosis using ultrasound. EPs were particularly sensitive in their diagnosis of decompensated cirrhosis.

Ruptured ectopic pregnancy is the leading cause of first trimester maternal mortality. The diagnosis of ectopic pregnancy should always be suspected in patients with abdominal pain, vaginal bleeding or syncope. While the use of an intrauterine device (IUD) markedly reduces the incidence of intrauterine pregnancy, it does not confer equal protection from the risk of ectopic pregnancy. In this report we discuss the case of a female patient who presented with a ruptured ectopic pregnancy and hemoperitoneum despite a correctly positioned IUD.