Systematic Review: Emergency Department Bedside Renal Ultrasonography for Diagnosing Nephrolithiasis

The Journal of Emergency Medicine image attributes is a better mechanism for quality assurance feedback and a more accurate indicator of trainee progress. To date there has been no widely accepted BUS image rating scale. Our aim was to introduce and report preliminary testing of a three-component, eight-point BUS rating scale (URS). Methods: Gallbladder BUS was selected as the test case. Twenty de-identified BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six US training sites, along with detailed instructions and examples for the URS. Each rated the BUS sets using the pilot URS. Training slides and sheets provided explanation, examples, and optimal anatomical landmarks for the URS. The URS rated ‘‘Landmarks(L)’’ from 1–5, ‘‘Image Quality(Q)’’ from 1–3, ‘‘Annotation(A)’’ from 1–2, for a ‘‘Total(T)’’ score range of 3–10. Raters also decided whether each BUS set would be ‘‘Clinically Useful’’ (yes or no)(U). Results: Among 13 faculty raters, experience averaged 7.8 years and 60 images reviewed per week (range 2–15, 5–300). Among all 16 raters, the mean scores were 2.93(L), 2.1(Q), 1.62(A), and 6.68(T) respectively. Kendall’s correlation coefficients were 0.55(L), 0.57(Q), 0.26(A), 0.63(T), and 0.45(U). All URS elements correlated significantly with Clinical Usefulness (p < 0.001). Spearman’s correlation coefficients between Clinical Usefulness and scoring elements were 0.40–0.66. Correlation coefficients between each reviewer and the entire group ranged from 0.31 to 0.69 and were independent of BUS review experience beyond fellowship. Conclusion: Our results suggest that development of a valid URS is feasible. The higher correlation for Landmarks and Total Scores may be an artifact of the wider scale ranges or the more explicit training for Landmarks. Next steps: raise the scale ranges to remove difficulties with only two to three choices, expand reviewer panel, and add organ systems. NOTE: This abstract is reprinted with permission of SAEM, Academic Emergency Medicine, 2011 Annual Meeting Issue, May 2011, Volume 18, Supplement s1. , CAN ULTRASOUND OF THE OPTIC NERVE SHEATH BE USED TO PREDICT AND MONITOR CHANGES IN INTRACRANIAL PRESSURE?. C. Butts, A. Stevens-Carrier, L. Moreno-Walton, Emergency Medicine, Louisiana State University School of Medicine, New Orleans, LA; L. Myers, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA. Objective: We seek to determine if serial measurements of the diameter of the optic nerve sheath made by ultrasound examination can reliably be used to monitor changes in intracranial pressure (ICP). Methods: A convenience sample of 16 patients identified in the emergency department as requiring placement of an invasive ICP monitor was chosen for this study. Using ultrasound, serial measurements of the optic nerve sheath diameter (ONSD) were taken and recorded at 30-min intervals after placement of the ICP monitor for the 4 h, and a single measurement was made and recorded at both 24 and 48 h. At each interval, the ICP as measured by the invasive ICP monitor was also recorded. Results: The data obtained were initially analyzed using both the Pearson correlation coefficients and scatter plots. Mixed model regression was then used to evaluate whether optic nerve diameter was a valid predictor of ventriculostomy mea-

213 surement. Time does not change the correlation between ONSD and ICP as measured by intracranial monitoring. There was a statistically significant relationship between the measurement of the right ONSD and ICP (p < 0.0001). There was a relationship between the left ONSD and ICP (p = 0.0013). The measurements of the right and left ONSD were found to consistently correlate with each other. Conclusion: There seems to be sufficient evidence to suggest that ultrasound of the optic nerve sheath can reliably be used to monitor changes in intracranial pressure over time. However, this relationship seems to be stronger using the right ONSD for evaluation than the left. , SYSTEMATIC REVIEW: EMERGENCY DEPARTMENT BEDSIDE RENAL ULTRASONOGRAPHY FOR DIAGNOSING NEPHROLITHIASIS. R. Sinert, J. Martin, R. Abdel-Naby, N. Mehta, Emergency Medicine, SUNY-Downstate Medical Center, Brooklyn, NY. Objective: The use of ultrasound to diagnose kidney stones has been well studied in the radiology literature. There is no systematic review of the Emergency Department (ED) experience with ultrasonography for diagnosing nephrolithiasis. We reviewed systematically the literature for the operating characteristics of ED ultrasonography for kidney stones. Methods: We searched PubMed and EMBASE databases for randomized controlled trials from 1965 through November 2010 using a search strategy derived from the following PICO formulation of our clinical question: Patients: Patients (18+ years) suspected of having a kidney stone. Intervention: Bedside ED ultrasonography to detect hydronephrosis or calculi. Comparator: Gold standard for kidney stones was either a non-enhanced computed tomography or intravenous pyelography scan. Outcome: Operating characteristics (sensitivity, specificity, predictive values, and likelihood ratios) of ED renal ultrasonography were analyzed using a forest plot (95% confidence interval) calculated by Review Manager Version 5.0 (Revman 5.0; Cochrane) Qualitative methods were used to summarize the study results. Results: Our initial search strategy identified 546 articles; 462 were excluded by relevance of title or abstract, 47 by not being in the ED, 25 with no kidney stone, and 10 retrospective, leaving two studies with 108 and 83 patients, respectively. Sensitivity was 90–72%, Specificity 59–73%, positive predictive value 72–58%, negative predictive value 28–42%, likelihood ratiopositive 2.12–2.67, likelihood ratio-negative 0.17–0.38. The heterogeneity between the two studies can be explained by the studies’ small sample sizes and variability in operator ultrasound experience. Conclusion: We identified two high-quality studies of the operating characteristics of ED bedside ultrasonography in diagnosing nephrolithiasis. Depending upon the pre-test probability of a patient with a kidney stone ED ultrasonography may be appropriate to diagnose but not exclude nephrolithiasis. , ULTRASOUND EVALUATION OF THE EFFECT OF HEAD ROTATION ON THE RELATIONSHIP OF THE INTERNAL JUGULAR VEIN AND CAROTID ARTERY. R. Merritt, C. Derr, E. Zellavous, K. Downes, L. Land, M. Lasseter, D. Denittis, R. Paula, USF/Team Health, Valrico, FL.