Network Five: POCUS

Network Five: Episode 3 – POCUS

Participants: Oliver Archer (ED resident and previous cardiac sonographer), Hung Diep (ED advanced trainee), Dr Richard McNulty, Dr Kenny Yee, Dr Pramod Chandru, Kit Rowe, Shreyas Iyer, Caroline Tyers and Samoda Wilegoda Mudalige.

Part 1

In this episode, the focus is on POCUS – we will be discussing the role, benefits, and potential pitfalls of POCUS in cardiac arrest. Presenter: Oliver Archer

• Atkinson PR, Beckett N, French J, Banerjee A, Fraser J, Lewis D. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019 Apr 13;11(4):e4456

Take-Home Points:

• This study showed that visualizing cardiac activity on ultrasound resulted in increased duration and effort of resuscitation, and was associated with improved clinical outcomes. 
• It is difficult to know whether the improved clinical outcomes were secondary to increased resuscitation efforts or due to identification (with ultrasound) of those with a better prognosis. 
• Ultimately, ultrasound should be used as an adjunct to your clinical decision-making, but should not get in the way of the established standard ALS protocol. 
• The COACHRED protocol (referenced below) assists in incorporating POCUS into the arrest algorithm.

Part 2

In this second part of the series, we look at diagnosing pulmonary embolism POCUS. Presenter: Hung Diep.

• Daley JI et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Acad Emerg Med. 2019 Nov;26(11):1211-1220

Take-Home Points:

• This study shows that focused cardiac ultrasound (FOCUS): involving right ventricular dilation, McConnell’s sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion (TAPSE), maybe a useful adjunct in the workup of patients with a high pre-test probability of PE.
• The most sensitive component of the FOCUS was TAPSE. 
• The most specific components of the FOCUS were McConnell’s sign and septal flattening. 
• However, it is important to remember that illnesses associated with chronic right heart strain such as COPD would also yield a positive FOCUS.
• At this stage, there is not enough evidence for FOCUS in diagnosing PE to alter clinical decision-making.  

Part 3

In this final part of the series, we probe into its use in the management of long bone fractures. Presenter: Pramod Chandru

• Chartier LB, Bosco L, Lapointe-Shaw L, Chenkin J. Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis. CJEM. 2017 Mar;19(2):131-142

Take-Home Points:

• This study looked at the use of POCUS to assist with both the diagnosis and reduction of long bone fractures (radius, ulna, humerus, tibia, fibula, and femur). 
• POCUS use had reasonable sensitivity and specificity in the diagnosis of fractures, particularly paediatric forearm fractures and adult ankle fractures – however, it may not provide all the information required regarding a fracture once identified. 
• In the absence of fluoroscopy, using POCUS to delineate the satisfactory nature of a reduction in ED (such as of the wrist) may reduce the risks associated with recurrent reductions and the need for operative fixation, however, further research with randomized controlled trials is needed.
• All in all, it is hard to see how ultrasound would replace x-ray as the imaging modality of choice for fractures, but there is an argument to be made for the use of ultrasound in assessing for the adequacy of reduction particularly in specific populations and this would be an interesting area for future studies.  

Other references

Interlude

• Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124

Other

• Finn TE, Ward JL, Wu CT, Giles A, Manivel V. COACHRED: A protocol for the safe and timely incorporation of focused echocardiography into the rhythm check during cardiopulmonary resuscitation. Emerg Med Australas. 2019 Dec;31(6):1115-1118

These episodes were produced with help of HETI’s Emergency Medicine Training Network 5. Please send us an email to let us know what you thought. You can contact us at [email protected]