- Email: [email protected]
2090165 The Impact of Ultrasound on Differential Diagnosis in Patients With Undifferentiated Abdominal Pain
Abstracts
Echocardiographic Evaluation (FREE); a hybrid between an FCU and the quantitative anatomic assessment of standard transthoracic echocardiogram (TTE). We sought to compare the data provided by the FREE and TTE, and determine the impact of the FREE on the plan of care. Methods: The FREE exam evaluates cardiac function (left ventricle ejection fraction (EF), diastolic dysfunction (E, E/ A, E’), RV function, cardiac output, preload (LV internal dimension end diastole (LVID)), stroke volume (SV), stroke volume variation (SVV), IVC and IVC collapse. Using clinical data and defined critical care algorithm, treatment recommendations are made. We identified patients who underwent both a TTE and FREE, on same day, from January 2012 through May 2014. Bland Altmann and Pearson correlation analysis were used to assess for agreement. Clinical utility was prospectively determined by provider survey immediately following the FREE, as part of its Q/A database. Results: Over the study period 849 FREE exams were performed. 69 patient exams met inclusion criteria. EF between groups showed a strong correlation (R5 0.89, 95% CI 0.820.93). Anatomic measures of LVOT, LVID, E and Lateral E’ also showed strong correlation (R50.84, R50.94, R50.77, R50.68 respectively). RV function was able to be assessed in 85% of patinets and agreed in 88% of these. Pericardial effusion evaluation agreed in 93% of patients. Aortic and mitral valve anatomy agreed in almost all patients assessed (100%, 98%). The FREE changed care in 53%, confirmed management 23%, and was found not useful in 23% of patients. Conclusions: Functional rather than anatomically based hybrid ultrasound exams, like the FREE, provide data in a format designed to facilitate decision making in the ICU. These exams can be reliably performed by the bedside intensivist, correlate well with TTE, and may be of greater clinical value in critically ill patients. Further work is needed to determine universal applicability of these findings. 2061835 The High-Frequency Linear Transducer Improves Detection of an Intrauterine Pregnancy in the First Trimester Matthew Tabbut,1 Devin Harper,1 Diane Gramer,1 Robert Jones1 1Emergency Department, MetroHealth Medical Center, Cleveland, OH, United States Objectives: Pelvic ultrasound is a component of the emergency department (ED) evaluation of symptomatic women in the first trimester. Transabdominal (TA) sonography with the curvilinear (CL) transducer is limited by resolution in the early stages of pregnancy. Patients for whom an intrauterine pregnancy (IUP) is not seen receive a transvaginal (TV) ultrasound to identify pregnancy location. A TA high-frequency linear (LN) transducer can provide greater imaging resolution. Our study attempts determine if the need for a TV can be decreased by the addition of the LN transducer after a failed examination with the CL transducer evaluating for sonographic evidence of an IUP. Methods: We conducted a single center, prospective, convenience sample of women in their first trimester of pregnancy in to the ED with abdominal pain and/or vaginal bleeding. Patients were included if they had a positive pregnancy test in the ED and had not been imaged during this pregnancy. Patients were first scanned using the CL transducer via the TA approach. If no IUP or definitive pregnancy was identified, they were subsequently scanned using the LN transducer. Patients without evidence of an IUP by TA were scanned via the TV approach. An
S33
IUP was defined by the sonographic presence of a yolk sac and/ or fetal pole within the uterus. Results: This is an ongoing, prospective study and to date 62 patients have been enrolled. One patient was excluded because a LN ultrasound was not performed. Of the remaining 61 patients no IUP was visualized in 18 with the CL transducer and had a LN ultrasound performed. Of these, 6 patients (33%, 0.95 CI 12-55%) were found to have an IUP with the LN transducer. Of the remaining 12 patients in whom an IUP was not identified with the LN transducer, 3 did not have a TV scan. For the 9 patients who received a TV scan, 8 patients (89%, 0.95 CI 68-100%) had no IUP identified and 1 (11%, 0.95 CI 0-32%) had an IUP identified with the TV transducer. Conclusions: The use of the linear transducer in the evaluation of patients in the first trimester after failed curvilinear transducer results in a clinically significant reduction in the need for TV ultrasonography in the ED to confirm the presence of an IUP. 2090953 Evaluation of Shoulder Injury in the Emergency Department: Utility of Bedside Ultrasound in the Diagnosis of Acute Shoulder Dislocation Shadi Lahham,1,2 Patrick Lenehan,1 Nathan Lane,1 Linda M. Joseph,1 Melika Hosseini,1 Alex Trinh,1 John Christian Fox1 1UC Irvine, Walnut, CA, United States; 2Department of Emergency Medicine, University of Nevada, School of Medicine, Las Vegas, NV, United States Objectives: Our study aims to determine the efficacy of ultrasound in diagnosing shoulder dislocations in patients presenting with acute shoulder pain. Methods: Bedside ultrasound was used to measure the distance between the humeral head and glenoid rim which is then compared to plain-film x-rays. Results: Eighty-one patients presenting to the ED with complaints of shoulder pain that were scheduled for conventional plain film x-ray were enrolled in the prospective observational study. Bedside ultrasound measurements exceeding an acceptable distance were compared to plain-film x-ray interpretations with a 93.3% sensitivity and 98.5% specificity for acute dislocation. Conclusions: This data suggests that ultrasound is an effective tool used to help clinicians diagnose anterior shoulder dislocations. 2090165 The Impact of Ultrasound on Differential Diagnosis in Patients With Undifferentiated Abdominal Pain Timothy Faust,1 Azeem Tajani,1 1 Jeanette Goldwaser, Philippe Louissaint,1 1 1 1 Arthur Au, Jason Fields Emergency Department, Thomas Jefferson University Hospital, Philadelphia, PA, United States Objectives: To determine the impact of a multi-part clinician-performed abdominal ultrasound (US) protocol on the differential diagnosis of patients with undifferentiated abdominal pain in the emergency department (ED). Methods: This was a prospective, interventional study in the ED of two hospitals from June to September, 2014. During periods of block enrollment, trained research
S34
Ultrasound in Medicine and Biology
associates enrolled consecutive adult patients with abdominal pain. Exclusion criteria included pregnancy, trauma or a recent (,24 hours) abdominal imaging study. After performing the history and physical, the treating physician was asked to indicate the differential diagnosis, primary diagnosis, confidence and imaging tests they planned to order. A different US-trained clinician performed a multi-part abdominal US (aorta, bowel, renal, biliary, free fluid assessment and pelvic in females). The US results were reported to the treating physician who indicated any change in differential diagnosis, primary diagnosis, confidence and imaging tests. Standard descriptive statistics were performed. Results: Sixty nine patients were enrolled of which 72% (50) were female. The mean age was 45 years (SD 19 years). Seventeen percent (95% CI 9-28%) (12/69) had a change in primary diagnosis following abdominal ultrasound. Of patients with no change in primary diagnosis, 70% (95% CI 57-82%) (40/57), had a change in confidence in the primary diagnosis, with a mean change in confidence of +9% (95% CI 6-12%). The breadth of differential diagnosis was narrowed in 42% (29/69) of cases, expanded in 9% (6/69) of cases, and unchanged in 49% (34/69) of cases following abdominal US. In only one case (1.4%) was there a reduction in the number of imaging tests ordered (an abdominal x-ray was cancelled). There was additional imaging ordered in five cases (7.2%) - 3 pelvic US and 2 CT studies. In one case, the CT protocol was changed. Overall, US affected ordering of diagnostic imaging in 9% (7/ 69) of cases. Conclusions: US impacted the differential diagnosis of abdominal pain in a substantial portion of cases, though the impact on utilization of imaging tests was small. The generalizability of these results should be explored in future studies. 2089557 High Body Mass Index is Strongly Correlated With Decreased Image Quality in Focused Bedside Echocardiography Sebastian Siadecki,1 Sarah E. Frasure,2 Turandot Saul,1 Resa E. Lewiss3 1Emergency Medicine, Mount Sinai St. Luke’s Mount Sinai Roosevelt, New York, NY, United States; 2Brigham and Women’s Hospital, Boston, MA, United States; 3 University of Colorado, Aurora, CO, United States Objectives: We sought to correlate obesity as measured by Body Mass Index (BMI) with image quality of focused bedside echocardiography (FOCUS) performed by emergency physicians. Methods: We conducted a prospective observational study between Nov. 2012 and Mar. 2014 in patients presenting to two academic emergency departments and an affiliated bariatric surgery outpatient clinic, in a convenience sample of emergency and ambulatory adult patients. 20 patients were enrolled in each of three BMI categories: , 30, 30-39, and $ 40. FOCUS was performed on each patient by an ultrasound fellowship-trained EP in the supine and left lateral decubitus positions. The heart was imaged in the subxiphoid, parasternal long axis, and parasternal short axis views. The resulting video clips were interpreted by a second ultrasound fellowship-trained EP who was blinded to BMI. Each clip was assigned two scores on a scale from 1 to 5 for image quality, one score for the ability to discern the myocardial/ pericardial interface and another for the ability to visualize global left ventricular function. Scores of 1-2 were considered
Volume 41, Number 4S, 2015
technically limited (TLS) and would be insufficient for diagnosis. Results: 23 males and 37 females were enrolled. The median age was 49 years and the median BMI was 35.6. There was a significant difference in the percentage of TLS examinations between BMI categories for both image quality scores. For the pericardial interface, there were 10% TLS in the BMI , 30 category, 10% in the BMI 30-39 category, and 50% in the BMI $ 40 category (p50.0069). For left ventricular function there were 10% TLS in the BMI , 30 category, 25% in the BMI 30-39 category, and 55% in the BMI $ 40 category (p50.0107). Additionally, there was an overall negative linear correlation between BMI and image quality for the pericardial interface (r 5 –0.65, p,0.0001) and left ventricular function (r 5 –0.60, p,0.0001). Conclusions: Our findings suggest that there is a decrease in the quality of FOCUS images as BMI increases for both the myocardial/pericardial interface and left ventricular function. Emergency physicians should be aware of the potential limitations of focused bedside echocardiography in this patient population. 2086716 This Isn’t Hocus POCUS- Point of Care Ultrasound to Diagnose Soft Tissue Neck Masses Marla Levine,1 Alexander Arroyo,1 2 Antonios Likourezos, Eitan Dickman2 1 Pediatric Emergency Department, Maimonides Medical Center, Brooklyn, NY, United States; 2 Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, United States Objectives: Neck masses are a common complaint to Pediatric Emergency Departments (PED). While most masses represent benign inflammatory or infectious processes, a broader differential must be considered. The aim of this study was to compare clinical assessment of soft tissue neck masses to radiology department imaging (RDI), and to compare point-of-care ultrasound (POCUS) to RDI in the diagnosis of soft tissue neck masses. Methods: This pilot study involved a convenience sample of children presenting to the PED with a soft tissue neck mass. The managing pediatric emergency medicine (PEM) provider determined a working diagnosis, followed by a POCUS which was performed by a sonologist not involved with the clinical care of the patient. The POCUS sonologist was blinded to the presumptive PEM provider diagnosis. The following list of possible diagnoses was considered for both POCUS and RDI examinations: Lymphadenitis, abscess, fibromatosis coli, thyroglossal duct cyst, branchial cleft cyst, and necrotic lymph node. The diagnoses of the PEM provider, POCUS, and RDI were compared. Fischer’s exact test was used with a p,.05 denoting a statistically significant difference. Results: Twenty-seven patients were studied: 22 received radiology ultrasound (RUS), 3 received CT, and 2 underwent both RUS and CT. RDI diagnostic concordance occurred with 55.6% of PEM provider clinical assessments and with 81.5% of POCUS diagnoses (P,.05). Conclusions: This pilot study described the utility of POCUS in the management of patients with soft tissue neck masses. In this study, POCUS demonstrated excellent agreement with RDI, and clinical assessment was found to be inaccurate in 45% of cases. POCUS is a useful diagnostic tool, which can aid in bedside medical decision-making when managing pediatric soft tissue neck masses.
Echocardiographic Evaluation (FREE); a hybrid between an FCU and the quantitative anatomic assessment of standard transthoracic echocardiogram (TTE). We sought to compare the data provided by the FREE and TTE, and determine the impact of the FREE on the plan of care. Methods: The FREE exam evaluates cardiac function (left ventricle ejection fraction (EF), diastolic dysfunction (E, E/ A, E’), RV function, cardiac output, preload (LV internal dimension end diastole (LVID)), stroke volume (SV), stroke volume variation (SVV), IVC and IVC collapse. Using clinical data and defined critical care algorithm, treatment recommendations are made. We identified patients who underwent both a TTE and FREE, on same day, from January 2012 through May 2014. Bland Altmann and Pearson correlation analysis were used to assess for agreement. Clinical utility was prospectively determined by provider survey immediately following the FREE, as part of its Q/A database. Results: Over the study period 849 FREE exams were performed. 69 patient exams met inclusion criteria. EF between groups showed a strong correlation (R5 0.89, 95% CI 0.820.93). Anatomic measures of LVOT, LVID, E and Lateral E’ also showed strong correlation (R50.84, R50.94, R50.77, R50.68 respectively). RV function was able to be assessed in 85% of patinets and agreed in 88% of these. Pericardial effusion evaluation agreed in 93% of patients. Aortic and mitral valve anatomy agreed in almost all patients assessed (100%, 98%). The FREE changed care in 53%, confirmed management 23%, and was found not useful in 23% of patients. Conclusions: Functional rather than anatomically based hybrid ultrasound exams, like the FREE, provide data in a format designed to facilitate decision making in the ICU. These exams can be reliably performed by the bedside intensivist, correlate well with TTE, and may be of greater clinical value in critically ill patients. Further work is needed to determine universal applicability of these findings. 2061835 The High-Frequency Linear Transducer Improves Detection of an Intrauterine Pregnancy in the First Trimester Matthew Tabbut,1 Devin Harper,1 Diane Gramer,1 Robert Jones1 1Emergency Department, MetroHealth Medical Center, Cleveland, OH, United States Objectives: Pelvic ultrasound is a component of the emergency department (ED) evaluation of symptomatic women in the first trimester. Transabdominal (TA) sonography with the curvilinear (CL) transducer is limited by resolution in the early stages of pregnancy. Patients for whom an intrauterine pregnancy (IUP) is not seen receive a transvaginal (TV) ultrasound to identify pregnancy location. A TA high-frequency linear (LN) transducer can provide greater imaging resolution. Our study attempts determine if the need for a TV can be decreased by the addition of the LN transducer after a failed examination with the CL transducer evaluating for sonographic evidence of an IUP. Methods: We conducted a single center, prospective, convenience sample of women in their first trimester of pregnancy in to the ED with abdominal pain and/or vaginal bleeding. Patients were included if they had a positive pregnancy test in the ED and had not been imaged during this pregnancy. Patients were first scanned using the CL transducer via the TA approach. If no IUP or definitive pregnancy was identified, they were subsequently scanned using the LN transducer. Patients without evidence of an IUP by TA were scanned via the TV approach. An
S33
IUP was defined by the sonographic presence of a yolk sac and/ or fetal pole within the uterus. Results: This is an ongoing, prospective study and to date 62 patients have been enrolled. One patient was excluded because a LN ultrasound was not performed. Of the remaining 61 patients no IUP was visualized in 18 with the CL transducer and had a LN ultrasound performed. Of these, 6 patients (33%, 0.95 CI 12-55%) were found to have an IUP with the LN transducer. Of the remaining 12 patients in whom an IUP was not identified with the LN transducer, 3 did not have a TV scan. For the 9 patients who received a TV scan, 8 patients (89%, 0.95 CI 68-100%) had no IUP identified and 1 (11%, 0.95 CI 0-32%) had an IUP identified with the TV transducer. Conclusions: The use of the linear transducer in the evaluation of patients in the first trimester after failed curvilinear transducer results in a clinically significant reduction in the need for TV ultrasonography in the ED to confirm the presence of an IUP. 2090953 Evaluation of Shoulder Injury in the Emergency Department: Utility of Bedside Ultrasound in the Diagnosis of Acute Shoulder Dislocation Shadi Lahham,1,2 Patrick Lenehan,1 Nathan Lane,1 Linda M. Joseph,1 Melika Hosseini,1 Alex Trinh,1 John Christian Fox1 1UC Irvine, Walnut, CA, United States; 2Department of Emergency Medicine, University of Nevada, School of Medicine, Las Vegas, NV, United States Objectives: Our study aims to determine the efficacy of ultrasound in diagnosing shoulder dislocations in patients presenting with acute shoulder pain. Methods: Bedside ultrasound was used to measure the distance between the humeral head and glenoid rim which is then compared to plain-film x-rays. Results: Eighty-one patients presenting to the ED with complaints of shoulder pain that were scheduled for conventional plain film x-ray were enrolled in the prospective observational study. Bedside ultrasound measurements exceeding an acceptable distance were compared to plain-film x-ray interpretations with a 93.3% sensitivity and 98.5% specificity for acute dislocation. Conclusions: This data suggests that ultrasound is an effective tool used to help clinicians diagnose anterior shoulder dislocations. 2090165 The Impact of Ultrasound on Differential Diagnosis in Patients With Undifferentiated Abdominal Pain Timothy Faust,1 Azeem Tajani,1 1 Jeanette Goldwaser, Philippe Louissaint,1 1 1 1 Arthur Au, Jason Fields Emergency Department, Thomas Jefferson University Hospital, Philadelphia, PA, United States Objectives: To determine the impact of a multi-part clinician-performed abdominal ultrasound (US) protocol on the differential diagnosis of patients with undifferentiated abdominal pain in the emergency department (ED). Methods: This was a prospective, interventional study in the ED of two hospitals from June to September, 2014. During periods of block enrollment, trained research
S34
Ultrasound in Medicine and Biology
associates enrolled consecutive adult patients with abdominal pain. Exclusion criteria included pregnancy, trauma or a recent (,24 hours) abdominal imaging study. After performing the history and physical, the treating physician was asked to indicate the differential diagnosis, primary diagnosis, confidence and imaging tests they planned to order. A different US-trained clinician performed a multi-part abdominal US (aorta, bowel, renal, biliary, free fluid assessment and pelvic in females). The US results were reported to the treating physician who indicated any change in differential diagnosis, primary diagnosis, confidence and imaging tests. Standard descriptive statistics were performed. Results: Sixty nine patients were enrolled of which 72% (50) were female. The mean age was 45 years (SD 19 years). Seventeen percent (95% CI 9-28%) (12/69) had a change in primary diagnosis following abdominal ultrasound. Of patients with no change in primary diagnosis, 70% (95% CI 57-82%) (40/57), had a change in confidence in the primary diagnosis, with a mean change in confidence of +9% (95% CI 6-12%). The breadth of differential diagnosis was narrowed in 42% (29/69) of cases, expanded in 9% (6/69) of cases, and unchanged in 49% (34/69) of cases following abdominal US. In only one case (1.4%) was there a reduction in the number of imaging tests ordered (an abdominal x-ray was cancelled). There was additional imaging ordered in five cases (7.2%) - 3 pelvic US and 2 CT studies. In one case, the CT protocol was changed. Overall, US affected ordering of diagnostic imaging in 9% (7/ 69) of cases. Conclusions: US impacted the differential diagnosis of abdominal pain in a substantial portion of cases, though the impact on utilization of imaging tests was small. The generalizability of these results should be explored in future studies. 2089557 High Body Mass Index is Strongly Correlated With Decreased Image Quality in Focused Bedside Echocardiography Sebastian Siadecki,1 Sarah E. Frasure,2 Turandot Saul,1 Resa E. Lewiss3 1Emergency Medicine, Mount Sinai St. Luke’s Mount Sinai Roosevelt, New York, NY, United States; 2Brigham and Women’s Hospital, Boston, MA, United States; 3 University of Colorado, Aurora, CO, United States Objectives: We sought to correlate obesity as measured by Body Mass Index (BMI) with image quality of focused bedside echocardiography (FOCUS) performed by emergency physicians. Methods: We conducted a prospective observational study between Nov. 2012 and Mar. 2014 in patients presenting to two academic emergency departments and an affiliated bariatric surgery outpatient clinic, in a convenience sample of emergency and ambulatory adult patients. 20 patients were enrolled in each of three BMI categories: , 30, 30-39, and $ 40. FOCUS was performed on each patient by an ultrasound fellowship-trained EP in the supine and left lateral decubitus positions. The heart was imaged in the subxiphoid, parasternal long axis, and parasternal short axis views. The resulting video clips were interpreted by a second ultrasound fellowship-trained EP who was blinded to BMI. Each clip was assigned two scores on a scale from 1 to 5 for image quality, one score for the ability to discern the myocardial/ pericardial interface and another for the ability to visualize global left ventricular function. Scores of 1-2 were considered
Volume 41, Number 4S, 2015
technically limited (TLS) and would be insufficient for diagnosis. Results: 23 males and 37 females were enrolled. The median age was 49 years and the median BMI was 35.6. There was a significant difference in the percentage of TLS examinations between BMI categories for both image quality scores. For the pericardial interface, there were 10% TLS in the BMI , 30 category, 10% in the BMI 30-39 category, and 50% in the BMI $ 40 category (p50.0069). For left ventricular function there were 10% TLS in the BMI , 30 category, 25% in the BMI 30-39 category, and 55% in the BMI $ 40 category (p50.0107). Additionally, there was an overall negative linear correlation between BMI and image quality for the pericardial interface (r 5 –0.65, p,0.0001) and left ventricular function (r 5 –0.60, p,0.0001). Conclusions: Our findings suggest that there is a decrease in the quality of FOCUS images as BMI increases for both the myocardial/pericardial interface and left ventricular function. Emergency physicians should be aware of the potential limitations of focused bedside echocardiography in this patient population. 2086716 This Isn’t Hocus POCUS- Point of Care Ultrasound to Diagnose Soft Tissue Neck Masses Marla Levine,1 Alexander Arroyo,1 2 Antonios Likourezos, Eitan Dickman2 1 Pediatric Emergency Department, Maimonides Medical Center, Brooklyn, NY, United States; 2 Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, United States Objectives: Neck masses are a common complaint to Pediatric Emergency Departments (PED). While most masses represent benign inflammatory or infectious processes, a broader differential must be considered. The aim of this study was to compare clinical assessment of soft tissue neck masses to radiology department imaging (RDI), and to compare point-of-care ultrasound (POCUS) to RDI in the diagnosis of soft tissue neck masses. Methods: This pilot study involved a convenience sample of children presenting to the PED with a soft tissue neck mass. The managing pediatric emergency medicine (PEM) provider determined a working diagnosis, followed by a POCUS which was performed by a sonologist not involved with the clinical care of the patient. The POCUS sonologist was blinded to the presumptive PEM provider diagnosis. The following list of possible diagnoses was considered for both POCUS and RDI examinations: Lymphadenitis, abscess, fibromatosis coli, thyroglossal duct cyst, branchial cleft cyst, and necrotic lymph node. The diagnoses of the PEM provider, POCUS, and RDI were compared. Fischer’s exact test was used with a p,.05 denoting a statistically significant difference. Results: Twenty-seven patients were studied: 22 received radiology ultrasound (RUS), 3 received CT, and 2 underwent both RUS and CT. RDI diagnostic concordance occurred with 55.6% of PEM provider clinical assessments and with 81.5% of POCUS diagnoses (P,.05). Conclusions: This pilot study described the utility of POCUS in the management of patients with soft tissue neck masses. In this study, POCUS demonstrated excellent agreement with RDI, and clinical assessment was found to be inaccurate in 45% of cases. POCUS is a useful diagnostic tool, which can aid in bedside medical decision-making when managing pediatric soft tissue neck masses.