POCUS journal最新文献

Emergent transvenous pacing can be performed for patients with an unstable bradyarrhythmia in the emergency department. While emergent transvenous pacemaker (TVP) placement is performed relatively rarely, its importance in the management of these patients requires emergency physicians to be familiar with the procedure. Point of care ultrasound (POCUS) is traditionally used for the initial vascular access associated with TVP placement but can also be indispensable in the subsequent placement and advancement of the TVP wire itself. This article discusses two cases and then outlines a general protocol that incorporates POCUS into a standard emergent TVP procedure. Further, we outline some common POCUS troubleshooting tactics to improve success and ways in which POCUS can rapidly identify complications.

Several complications can arise during or shortly after the placement of a temporary transvenous pacemaker (TTP), some of which can be potentially devastating. A TTP was successfully placed under the guidance of point of care ultrasound (POCUS) and intracavitary electrocardiogram (ECG) in a middle-aged woman with symptomatic complete atrioventricular block. Three days post-insertion, pacemaker malfunction was observed along with the migration of the pacing lead to the left ventricular apex on cardiac POCUS. The lead was promptly repositioned, and no complications were noted on subsequent cardiac POCUS examinations. To prevent complications and aid early detection of complications associated with TTPs, cardiac POCUS should be strongly considered.

Introduction: This case series describes a point of care ultrasound (POCUS) artifact involving the abdominal aorta of four standardized patients. The purpose of this case series is to highlight this artifact and maneuvers to discern pathology from normal.

Methods: Permission was obtained for each case described in this series. POCUS images of the abdominal aorta in both sagittal and transverse were obtained in these four cases. The findings were reviewed and compared.

Discussion: All four standardized patients were otherwise healthy, thin and female. The artifact was consistently a linear, hyperechoic structure within the lumen of the abdominal aorta in the sagittal plane.

Conclusion: In each of these cases, the artifact disappeared on rotation of the probe from the sagittal plane to the transverse plane. Knowledge of this POCUS artifact and maneuvers to avoid it are important in both clinical and educational settings.

Background: Lung point of care ultrasound (POCUS) has the potential to transform pediatric pneumonia care in low resource settings. Prior studies of novice POCUS users in such settings showed high agreement with remote POCUS experts for diagnosing pediatric pneumonia, but use of remote experts may falsely inflate this agreement.

Objectives: This study aimed to 1. Deliver a train-the-trainer program in Pakistan on lung POCUS for diagnosing pediatric pneumonia; 2. Determine inter-rater reliability between i) study-trained community health workers (CHWs) and a remote expert, with both interpreting POCUS examinations acquired by the CHWs, and ii) study-trained CHWs and local champions, with both interpreting examinations that they had acquired.

Methods: Phase 1: Canadian pediatric POCUS experts developed and delivered a lung POCUS training program for two user groups in Pakistan. These groups included local champions (who had POCUS experience) and CHWs (who were POCUS novices). Phase 2: Children with suspected pneumonia underwent two lung POCUS examinations, one by a CHW and one by a local champion. Examinations were recorded and later reviewed by a remote expert for interpretation and quality assurance. Inter-rater reliability was determined.

Results: Two local champions and three CHWs were successfully trained. An analysis of 231 recruited patients showed strong inter-rater reliability between study-trained CHWs and remote expert interpretations (κ = 0.83). In contrast, inter-rater reliability was moderate (κ = 0.66) between interpretations by novices and local champions when these users interpreted the examinations that they themselves had acquired.

Conclusion: Our study showed that train-the-trainer programs are feasible and can be effective, while highlighting the importance of hands-on training and having local champions provide longitudinal support to novices.

Isolated right ventricular myocardial infarction (RVMI) is a rare but significant clinical entity that can present with atypical findings on a standard electrocardiograph (ECG). We present the case of a 65-year-old man with a history of chronic smoking and alcohol use who presented to the emergency department with acute chest pain. An initial ECG showed ST-segment elevation in lead V1 and depression in leads I, aVL, and V2-V6, which did not meet ST-segment elevation myocardial infarction (STEMI) criteria. A right-sided ECG revealed ST-segment elevation in V3R-V6R, concerning for RVMI. Notably, cardiac point of care ultrasound (POCUS) demonstrated normal left ventricular (LV) function without LV or right ventricular (RV) regional wall motion abnormalities (RWMA). However, tricuspid annular plane systolic excursion (TAPSE) was significantly reduced at 1 cm, indicating RV dysfunction despite the absence of RWMA. This is the first known case report that highlights the importance of TAPSE in assessing RV function in isolated RVMI cases. Early recognition and management are crucial, especially in patients with typical presentations, as prompt treatment can prevent complications. This case underscores the need for emergency physicians to maintain a high index of suspicion for RVMI, particularly in atypical presentations, and to utilize cardiac POCUS as an essential tool for evaluation.

Point of care ultrasound of the lungs has emerged as a crucial tool in the evaluation of hypoxemia in critical care and hospital medicine settings. The ability to distinguish the horizontal A-line artifact from other lung pathology is essential for guiding clinical decision making. Typically, ribs and their acoustic shadows are used as anchoring anatomy to ensure visualization of pleura and parenchyma. We present a case of horizontal reverberation artifacts incidentally observed over a rib during a point of care lung ultrasound (LUS) in a 77-year-old patient with persistent hypoxic respiratory failure. Describing these reverberation artifacts caused by ribs is important to decrease the chance of misinterpretation.

Fibromatosis colli is a rare benign fibrosis of the sternocleidomastoid (SCM) muscle which manifests clinically as congenital muscular torticollis, or an ipsilateral head tilt with contralateral turning of the neck. Though benign, care must be taken not to miss other etiologies with similar clinical presentations, such as malignancies or abscesses. Point of care ultrasound (POCUS) offers a rapid, low-cost, and accessible option for adjunct imaging. In this case report, a 26-day-old boy presented to the pediatric emergency department for evaluation of a nontender, firm left-sided neck mass with preferential turning of his head to the right. POCUS showed a noncompressible, homogenous, well-defined mass in the left SCM without increased vascularity consistent with fibromatosis colli. The patient was discharged from the emergency department with outpatient follow-up. His follow-up course required no further imaging or testing, and the patient's symptoms resolved with physical therapy.

Background: Chest point of care ultrasound (POCUS) is a first-line diagnostic test to identify lung sliding, an important artifact to diagnose or rule out pneumothorax. Despite enthusiastic adoption of this modality, the interrater reliability for physicians to identify lung sliding is unknown. Additionally, the relative diagnostic performance of physicians interpreting B-mode and M-mode ultrasound is unclear. We sought to determine the interrater reliability of physicians to detect lung sliding on B-mode and M-mode POCUS.

Methods: We performed a cross-sectional interrater agreement study surveying acute care physicians on their interpretation of 20 B-mode and M-mode POCUS clips. Two experienced clinicians determined the reference standard diagnosis. Respondents reported their interpretation of each POCUS B-mode clip or M-mode image. The primary outcome was the interrater agreement, determined by an intra-class correlation coefficient (ICC).

Results: From September to November 2023, there were 20 survey respondents. Fourteen (70%) respondents were resident physicians. Respondents were confident or very confident in their skill performing chest POCUS in 14 (70%) cases, with 19 (90%) performing chest POCUS every week or more frequently. The ICC on B-mode was 0.44 and for M-mode was 0.43, indicating moderate agreement. There were no significant differences in interrater reliability between subgroups of confidence or experience.

Conclusion: There is only moderate interrater reliability between clinicians to diagnose lung sliding. Clinicians have superior accuracy on B-mode compared to M-mode clips.

Background: Few studies have examined internal medicine residents' performance using cardiovascular point of care ultrasound (POCUS).

Methods: From 2019 to 2022, first-year residents from two academic medical centers in Baltimore participated in the Assessment of Examination and Communication Skills (APECS). Interns examined a single patient with aortic insufficiency and were assessed on physical exam and POCUS technique, identifying physical exam and POCUS findings, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam and POCUS exam technique and in identifying correct findings.

Results: Fifty-three first-year residents (interns) performed a cardiovascular POCUS exam. Of these, 44 (83%) scored either "unsatisfactory" or "borderline" on their POCUS technique with a mean score of 29.5 (out of 100). Seventeen (32%) interns were able to correctly obtain a parasternal-long axis (PLAX) view with only 26 (52%) attempting an apical four-chamber (AP4) or subcostal (SUBC) view. Of the 11 participants who correctly obtained both PLAX and parasternal-short views (PSAX), 10 were able to properly identify a normal ejection fraction and the absence of a pericardial effusion. POCUS technique was statistically significantly associated with physical exam technique, identifying the correct POCUS findings, and generating a correct differential diagnosis (r=0.46, p<0.01; r=0.41, p=<0.01; r=0.60, p=<0.01, respectively).

Conclusion: Internal medicine interns showed variable skill in performing and interpreting a cardiovascular POCUS exam. Further emphasis on teaching cardiovascular POCUS skills would likely increase ability to identify relevant cardiovascular findings and improve patient care.

Each year, more than 200,000 thoracentesis and percutaneous chest tube thoracostomy procedures are performed in the United States [1-4]. In both procedures, the initial step involves advancing a needle over the superior aspect of the rib into the intercostal space to access the pleural cavity. Traditional teaching suggests that this technique avoids the neurovascular bundle, which is typically shielded by the inferior border of the rib. However, this technique does not guarantee safety. Computed tomography studies have shown that the intercostal arteries (ICAs) are highly tortuous, with positions that can vary significantly within the intercostal space [5-7]. This variability can lead to ICA laceration even with an optimal traditional technique [8-9]. Significant hemorrhage into the pleural space may initially go unnoticed but can progress to hemorrhagic shock or even tension hemothorax physiology [10-12]. Improved procedural guidance is needed to enhance safety and achieve the goal of zero patient harm. We propose the DIVOT (Doppler Imaging for Vascular Orientation in Thoracic procedures) protocol using a combination of high-frequency linear ultrasound, color, and Power Doppler (PD) to identify an ICA and its collaterals before needle insertion. This can reduce the risk of accidental vascular injury during thoracentesis or percutaneous chest tube thoracostomy.