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247: Observed Structured Clinical Examination to Determine Competency In Abdominal Aorta Ultrasonographic Examination Performed by Emergency Physicians
Research Forum Abstracts were excluded if there was already a definitive imaging study. After informed consent, the emergency physcian ultrasonographer used a high-frequency linear probe to identify and measure the pylorus. Images were saved in digital format for quality assurance and compared to the subsequent radiology ultrasonography. Results: To date, 22 patients have been enrolled and 14 (64%) were male. Mean age was 35 days (range 13 - 111 days), mean duration of symptoms was 125 hours (range 12 - 720 hours), and 20 (86%) had parent-reported projectile vomiting. Two patients had surgical correction for HPS. The sensitivity and specificity of the emergency physcian ultrasonography was 100% (95% confidence interval 0.34-1) and 100% (0.84-1). There was no statistical difference between emergency physcian and radiology measurements of pyloric width (p⫽0.36) or length (p⫽0.14). Conclusion: Emergency physcian ultrasonography can accurately identify and measure the pylorus and may be a useful adjunct in the evaluation and diagnosis of HPS.
245
Test Characteristics of Sonographic Evaluation of IVC Maximum Diameter and IVC Collapsibility Index In Predicting Congestive Heart Failure Among Dyspneic Patients In the Emergency Department
Anderson KL, Fields JM, Jenq K, Mangili A, Panebianco N, Dean AJ/University of Pennsylvania, Philadelphia, PA
Study Objectives: Emergency bedside ultrasonography (EMBU) assessment of the inferior vena cava (IVC) for signs of increased right atrial pressure (RAP) may contribute to the evaluation of dyspneic patients by helping to distinguish CHF and non-cardiac causes of dyspnea. Both maximal IVC diameter and IVC respirophasic collapsibility index (IVC-CI) are related to RAP. In this study we compare the two variables in dyspneic ED patients to determine their test characteristics in diagnosing CHF. We tested the nullhypothesis that both variables would perform equally in diagnosing CHF. Methods: This prospective study was performed in the ED of an urban academic medical center, annual census 55,000, using a convenience sample of dyspneic patients, age ⱖ18, with differential Dx including CHF. EMBU was performed by emergency physicians with experience in bedside echocardiography. Maximum and minimum IVC diameters were recorded using M-mode images. The IVC-CI was calculated as (IVC maximum - IVC minimum)/(IVC maximum). Receiver operator characteristic (ROC) curves with confidence intervals (CI) were generated to determine optimal cutoffs of IVC parameters in predicting CHF using standard methods. The criterion standard for presence or absence of CHF was determined by 2 blinded physicians’ review of all clinical data relating to the ED visit (including admission, if applicable). Results: 89 of 94 subjects had adequate IVC views, 57% male, median age 63. 36(40%) had a final diagnosis of CHF. Area under the ROC curve for maximal IVC diameter predicting CHF was 74% (95CI 64-82%). Area under the ROC curve for IVC-CI predicting CHF was 71% (95CI 61-80%). The difference between the two areas was 3.0% (95CI -11-16%). An IVC maximum dimension of 2.0 cm and IVC collapsibility of ⱕ15% were the optimal cutoffs to predict CHF. Conclusion: IVC ultrasonography evaluation of maximum diameter and of IVCCI provide useful information in distinguishing dyspneic patients with and without CHF in the ED. There is no difference in the accuracy of IVC maximal diameter and IVC-CI in the diagnosis of CHF.
246
Comparison of Physical Examination and Point of Care Ultrasonography In the Evaluation of Peritoneal Fluid
Dean TD, Diercks D, Nishijima D, Ingram D, Cusick S/University of California, Davis Medical Center, Sacramento, CA
Study Objectives: The diagnosis of peritoneal fluid by physical examination alone is often unreliable and may lead to unnecessary paracentesis. The objective of this study was to compare a focused abdominal examination to point of care ultrasonography (US) for the diagnosis of peritoneal fluid. We hypothesized that point of care US improves diagnostic accuracy over physical examination alone in the evaluation of peritoneal fluid. Methods: Physicians from varied specialties and level of training performed a blinded focused abdominal examination and point of care US on five model patients: two with peritoneal fluid and three without peritoneal fluid. The mean model patient age was 62 years old with a mean body mass index of 29. To assess for peritoneal fluid, physicians initially performed a focused abdominal examination. After findings
Volume , . : September
were recorded, a second exam with point of care US was performed. The gold standard for identification of peritoneal fluid was expert point of care US. Measures of diagnostic accuracy with 95% confidence intervals are reported. The area under the curve of physical examination and point of care US were also compared. Results: Nineteen physicians: three emergency medicine attendings, ten emergency medicine residents and six internal medicine residents performed seventyone examinations: 40 examinations on model patients without peritoneal fluid and 31 examinations on model patients with peritoneal fluid. Measures of diagnostic accuracy with 95% confidence intervals are shown below. There is no statistically significant difference in the area under the curve for physical examination 0.75 (95% CI 0.65-0.86) and point of care US 0.84 (95% CI 0.75-0.93) (p⫽0.09). In a subclass analysis of patients without peritoneal fluid (n⫽40), the use of US reduced unnecessary paracentesis with an absolute risk reduction of 17.5% and a number needed to harm of 5.7 patients.
Conclusions: In this pilot study, point of care US showed a trend toward improved diagnostic accuracy when compared to physical examination alone in the evaluation of peritoneal fluid in a select patient population. The use of point of care US resulted in a reduction in unnecessary paracentesis with a number needed to harm of 5.7 patients.
247
Observed Structured Clinical Examination to Determine Competency In Abdominal Aorta Ultrasonographic Examination Performed by Emergency Physicians
Peterson B, Rifenburg RP/Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, Illinois, Chicago, IL
Study Objectives: Abdominal aorta emergencies are associated with significant morbidity and mortality. Bedside abdominal aorta ultrasonography (BAAU) can rapidly and effectively diagnose potentially catastrophic conditions when utilized by experienced, qualified practitioners. The ACEP recommended guidelines of twenty-five recorded and reviewed BAAU examinations for considered competency has not been methodologically studied. The objective of this study is to evaluate the experience and abilities of resident and attending physicians in performing abdominal aorta ultrasonographic examinations to validate current ACEP recommendations and guidelines. Methods: Attending and resident physicians from a 3-year emergency medicine residency program were shown abdominal aorta ultrasonography examination video clips and asked to identify basic anatomical structures in a written examination. They also performed BAAU practical examinations on a standardized patient. Their performance in the written examination and proficiency in performing bedside ultrasonographic examinations were correlated with their level of training and BAAU experience. Results: 11 attending and 34 resident physicians participated in the study with mean prior experience of 35.4 (SD: 43.6) and 15.6 (SD:9.0) BAAU examinations respectively. There was no significant difference among study participants between written, practical, or combined scores when stratified by training level and/or BAAU experience (P ⫽.146 and P ⫽ .649). However, using ROC analysis, there is suggestion that between 10-13 BAAU examinations, performers reach an optimal cut-off point for scoring 75% or greater combined score. Conclusion: While neither level of training nor prior BAAU experience were statistically significant in relationship to performance on written and practical examinations, our findings suggest that between 10-13 BAAU examinations are associated with examination scores ⬎ 75%. This small study provides evidence that the ACEP recommendation of 25 abdominal aortic ultrasonography scans is more than sufficient to score well on a simulated examination.
248
Internal Jugular Vein Collapsibility Index Seen With Hypovolemia In Critically Ill Patients
Coba V, Andrzejewski T, Huang Y, Brackney A, Killu K/Henry Ford Hospital, Detroit, MI
Background: Current point of care ultrasonography practice has described evaluation for inferior vena cava (IVC) collapsibility index of greater than 50% being associated with hypovolemia in critically ill patients. No current literature to date has described the clinical utility of the internal jugular vein (IJV) collapsibility index.
Annals of Emergency Medicine S81
245
Test Characteristics of Sonographic Evaluation of IVC Maximum Diameter and IVC Collapsibility Index In Predicting Congestive Heart Failure Among Dyspneic Patients In the Emergency Department
Anderson KL, Fields JM, Jenq K, Mangili A, Panebianco N, Dean AJ/University of Pennsylvania, Philadelphia, PA
Study Objectives: Emergency bedside ultrasonography (EMBU) assessment of the inferior vena cava (IVC) for signs of increased right atrial pressure (RAP) may contribute to the evaluation of dyspneic patients by helping to distinguish CHF and non-cardiac causes of dyspnea. Both maximal IVC diameter and IVC respirophasic collapsibility index (IVC-CI) are related to RAP. In this study we compare the two variables in dyspneic ED patients to determine their test characteristics in diagnosing CHF. We tested the nullhypothesis that both variables would perform equally in diagnosing CHF. Methods: This prospective study was performed in the ED of an urban academic medical center, annual census 55,000, using a convenience sample of dyspneic patients, age ⱖ18, with differential Dx including CHF. EMBU was performed by emergency physicians with experience in bedside echocardiography. Maximum and minimum IVC diameters were recorded using M-mode images. The IVC-CI was calculated as (IVC maximum - IVC minimum)/(IVC maximum). Receiver operator characteristic (ROC) curves with confidence intervals (CI) were generated to determine optimal cutoffs of IVC parameters in predicting CHF using standard methods. The criterion standard for presence or absence of CHF was determined by 2 blinded physicians’ review of all clinical data relating to the ED visit (including admission, if applicable). Results: 89 of 94 subjects had adequate IVC views, 57% male, median age 63. 36(40%) had a final diagnosis of CHF. Area under the ROC curve for maximal IVC diameter predicting CHF was 74% (95CI 64-82%). Area under the ROC curve for IVC-CI predicting CHF was 71% (95CI 61-80%). The difference between the two areas was 3.0% (95CI -11-16%). An IVC maximum dimension of 2.0 cm and IVC collapsibility of ⱕ15% were the optimal cutoffs to predict CHF. Conclusion: IVC ultrasonography evaluation of maximum diameter and of IVCCI provide useful information in distinguishing dyspneic patients with and without CHF in the ED. There is no difference in the accuracy of IVC maximal diameter and IVC-CI in the diagnosis of CHF.
246
Comparison of Physical Examination and Point of Care Ultrasonography In the Evaluation of Peritoneal Fluid
Dean TD, Diercks D, Nishijima D, Ingram D, Cusick S/University of California, Davis Medical Center, Sacramento, CA
Study Objectives: The diagnosis of peritoneal fluid by physical examination alone is often unreliable and may lead to unnecessary paracentesis. The objective of this study was to compare a focused abdominal examination to point of care ultrasonography (US) for the diagnosis of peritoneal fluid. We hypothesized that point of care US improves diagnostic accuracy over physical examination alone in the evaluation of peritoneal fluid. Methods: Physicians from varied specialties and level of training performed a blinded focused abdominal examination and point of care US on five model patients: two with peritoneal fluid and three without peritoneal fluid. The mean model patient age was 62 years old with a mean body mass index of 29. To assess for peritoneal fluid, physicians initially performed a focused abdominal examination. After findings
Volume , . : September
were recorded, a second exam with point of care US was performed. The gold standard for identification of peritoneal fluid was expert point of care US. Measures of diagnostic accuracy with 95% confidence intervals are reported. The area under the curve of physical examination and point of care US were also compared. Results: Nineteen physicians: three emergency medicine attendings, ten emergency medicine residents and six internal medicine residents performed seventyone examinations: 40 examinations on model patients without peritoneal fluid and 31 examinations on model patients with peritoneal fluid. Measures of diagnostic accuracy with 95% confidence intervals are shown below. There is no statistically significant difference in the area under the curve for physical examination 0.75 (95% CI 0.65-0.86) and point of care US 0.84 (95% CI 0.75-0.93) (p⫽0.09). In a subclass analysis of patients without peritoneal fluid (n⫽40), the use of US reduced unnecessary paracentesis with an absolute risk reduction of 17.5% and a number needed to harm of 5.7 patients.
Conclusions: In this pilot study, point of care US showed a trend toward improved diagnostic accuracy when compared to physical examination alone in the evaluation of peritoneal fluid in a select patient population. The use of point of care US resulted in a reduction in unnecessary paracentesis with a number needed to harm of 5.7 patients.
247
Observed Structured Clinical Examination to Determine Competency In Abdominal Aorta Ultrasonographic Examination Performed by Emergency Physicians
Peterson B, Rifenburg RP/Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, Illinois, Chicago, IL
Study Objectives: Abdominal aorta emergencies are associated with significant morbidity and mortality. Bedside abdominal aorta ultrasonography (BAAU) can rapidly and effectively diagnose potentially catastrophic conditions when utilized by experienced, qualified practitioners. The ACEP recommended guidelines of twenty-five recorded and reviewed BAAU examinations for considered competency has not been methodologically studied. The objective of this study is to evaluate the experience and abilities of resident and attending physicians in performing abdominal aorta ultrasonographic examinations to validate current ACEP recommendations and guidelines. Methods: Attending and resident physicians from a 3-year emergency medicine residency program were shown abdominal aorta ultrasonography examination video clips and asked to identify basic anatomical structures in a written examination. They also performed BAAU practical examinations on a standardized patient. Their performance in the written examination and proficiency in performing bedside ultrasonographic examinations were correlated with their level of training and BAAU experience. Results: 11 attending and 34 resident physicians participated in the study with mean prior experience of 35.4 (SD: 43.6) and 15.6 (SD:9.0) BAAU examinations respectively. There was no significant difference among study participants between written, practical, or combined scores when stratified by training level and/or BAAU experience (P ⫽.146 and P ⫽ .649). However, using ROC analysis, there is suggestion that between 10-13 BAAU examinations, performers reach an optimal cut-off point for scoring 75% or greater combined score. Conclusion: While neither level of training nor prior BAAU experience were statistically significant in relationship to performance on written and practical examinations, our findings suggest that between 10-13 BAAU examinations are associated with examination scores ⬎ 75%. This small study provides evidence that the ACEP recommendation of 25 abdominal aortic ultrasonography scans is more than sufficient to score well on a simulated examination.
248
Internal Jugular Vein Collapsibility Index Seen With Hypovolemia In Critically Ill Patients
Coba V, Andrzejewski T, Huang Y, Brackney A, Killu K/Henry Ford Hospital, Detroit, MI
Background: Current point of care ultrasonography practice has described evaluation for inferior vena cava (IVC) collapsibility index of greater than 50% being associated with hypovolemia in critically ill patients. No current literature to date has described the clinical utility of the internal jugular vein (IJV) collapsibility index.
Annals of Emergency Medicine S81