Emergency Ultrasound

Journal Summary

Point of Care Ultrasound quickly identifies source of sepsis and helps guide appropriate antibiotic selection
Review by Michael Boniface, MD

Accuracy of point of care to identify the source of infection in septic patients: a prospective study.
Cortellaro F, Ferrari L, Molteni F, et al. Intern Emerg Med. 2016 May 28. [Epub ahead of print].

This prospective, single center study from Italy sought to demonstrate the utility of point-of-care ultrasound (PoCUS) in determining the source of infection in patients presenting to the emergency department meeting criteria for sepsis (two or more SIRS criteria and a presumed source of infection). Over a 6 month period 200 patients were enrolled. Treating emergency physicians were required to document a clinical impression of source and appropriate directed antibiotic therapy both 1) following H&P, ABG, and lactate, and 2) after ED-physician performed PoCUS. Reference standard for source of infection to use for statistical calculations was expert consensus following hospital discharge after review of all available records (except ED PoCUS). ED physicians evaluated the lung, abdomen, cardiac, joints, and soft tissue as necessary until presumed source was identified. This examination took less than 10 minutes. Ultimately, 178/200 patients had a consensus source. The sensitivity and specificity for source based on clinical exam was 48% and 86%, respectively. Source identification by PoCUS had markedly improved sensitivity and specificity of 73% and 95%. PoCUS altered initial therapy such as antibiotic selection in 24% of cases. Among the 48 cases that PoCUS did not identify source, 30 were ultimately due to urinary tract infection. Whereas the PoCUS-determined source was documented within 10 minutes, diagnosis by standard workup required several hours, with only 52.8% of cases within 3 hours. This is a great single-center non-randomized study demonstrating how PoCUS can improve both diagnostic accuracy and guide management as well as expediting time to diagnosis. The operators were all emergency physicians with WINFOCUS certification in emergency ultrasound, possibly limiting the generalizability to all emergency physicians, but this study is otherwise an excellent demonstration of what many of us already suspected. Strongly consider incorporating this into your practice.

If you don’t use them, you will lose them - There was poor retention of cardiac ultrasound skills in residents who did not use them regularly.
Review by Tomislav Jelic, MD

Retention of Ultrasound Skills and Training in “Point-of-Care” Cardiac Ultrasound

Kimura B, Sliman SM, Waalen J, et al. J Am Soc Echocardiogr. e-Pub. 2016 Jun 29

This study published in the Journal of the American Society of Echocardiography aimed to assess the skills retained for focused echocardiographic assessment. The study was conducted at a single, university based hospital, using internal medicine residents. 10 residents per year participated in a 3 year ultrasound curriculum, with a total of 74 residents enrolled in the study. None of the enrolled residents had any previous ultrasound training. Residents were taught the CLUE (Cardiac Limited Ultrasound Exam) ultrasound curriculum, which consisted of the following; 1) parasternal long axis, 2) apical 4 chamber, 3) subcostal, 4) IVC, 5) abdominal aorta, 6) carotid artery and 7) pulmonary. Prior to graduation, the residents were required to complete a CLUE-CEX assessment process, with a passing score of 80% required on the final assessment. The CLUE-CEX assessment involved image acquisition, interpretation and quality of image generated.

61/74 residents passed the CLUE-CEX exam. Of those 30 agreed to take a repeat CLUE-CEX assessment. Of those 30 residents, 20 were placed in a no-prep group. The remaining 10 were allowed prep and review of the CLUE protocol.

In the no-prep group, 7/20 physicians were within 1 year of their last use of ultrasound, compared to 1/10 in the prep group. In the no-prep group who had >1 year of non-use, none repassed their CLUE-CEX assessment. In the prep group, 3/10 passed who had >1 year since last use. The study showed that after 2 years since use, there is sharp drop off in the retention and ability to perform the PoCUS assessment.

There are several strengths to the study, which include that none of the learners underwent any further cardiology training. Furthermore, the group studied was had no ultrasound “superusers” in it, further adding to the generalizability of this study. There was a slight improvement in the prep group, showing that with minimal review, users did better than those in the no-prep group. This study shows us that learners in short, brief courses are less likely to retain what they have learned for future use. This study adds to the paucity of literature in how to best train and learn ultrasound, and to maximize retention.

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